Columbm  ?Emtiers(tt|> 
in  tf^t  Citp  of  iBeto  |9orfe 


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FIG.  I. 


Fig.  I.  Arteriosclerosis  of  the  thoracic  and  abdomina, 
aorta,  showing  irregular  nodules,  atheromatous  plaquesl 
denudation  of  the  intinia,  thin  plates  of  bone  scattered 
throughout  with  spicules  extending  into  the  lumen  of  the 
vessel.  Note  the  contraction  of  the  openings  of  the  large 
branches,  the  rough  appearance  of  the  aorta  and  the  greater 
degree  of  sclerosis  of  the  upper  two-thirds,  i.  e.,  of  the 
aorta  above  the  diaphragm.  This  aorta  in  the  recent 
state  was  much  thickened  and  almost  inelastic. 


Arteriosclerosis: 

Etiology,  Pathology,  Diagnosis,  Prognosis, 
Prophylaxis,  and  Treatment. 

By 

Louis  M.  Warficid,  A.  B.,  M.  D. 

lastructof  in  Medicine,  Washington  University  Medical   Depart- 
ment; Physician  to  the  Protestant  Hospital;  Adjunct  Attending 
Physician  to  the  Martha  Parsons  Hospital   for  Children, 
St,  Louis»  Mo.  Formerly   Medical  House  Officer  at 
The  Johns  Hopkins   Hospital,  Baltimore,  Md, 
Member  St .  Louis  Medical  Society,  Missouri 
State   Medical   Society,    and  American 
Medical   Association,    etc. 

With  an  introduction 
by 

W.  S.  Thayer,  M.  D., 

Professor  of  Clinical  Medicine,  Johns  Hopkins  University. 
Eight  original  illustrations. 

C.  V.  Mosby  Medical  Book  Co., 

St.  Louis,  Mo. 

J908. 


Copyright,  1908 

by 

C.  V.  MosBY  Book  and  Publishing  Co. 

St.  Louis 


n 


This  volume  is  affectionately  dedicated 
to  my  mother. 

— The  Author. 


in 


PREFACE. 

It  is  hoped  that  this  small  volume  may 
fill  a  want  in  the  already  crowded  field  of 
medical  monographs.  Our  attempt  has  been 
to  give  to  the  general  practitioner  a  readable, 
authoritative  essay  on  a  disease  which  is  es- 
pecially an  outcome  of  modern  civilization. 
To  that  end  all  the  available  literature  has 
been  freely  consulted,  and  the  newest  results 
of  experimental  research  and  the  recent 
ideas  of  leading  clinicians  have  been  summar- 
ized. The  writer  has  supplemented  these 
with  results  from  his  own  experience  but  has 
thought  it  best  not  to  burden  the  contents 
with  case  histories. 

The  stress  and  strain  of  our  daily  life  has, 
as  one  of  its  consequences,  early  arterial 
degeneration.  There  can  be  no  doubt  that 
arterial  disease  in  the  comparatively  young 
is  more  frequent  than  it  was  twenty-five 
years  ago,  and  that  the  mortality  from  dis- 
eases directly  dependent  on  arteriosclerotic 
changes  is  increasing.     Fortunately,  the  al- 


most  universal  habit  of  getting  out-of-doors 
whenever  possible,  and  the  revival  of  in- 
terest in  athletics  for  persons  of  all  ages, 
have  to  some  extent  counteracted  the  tend- 
ency to  early  decay.  Nevertheless,  the  act- 
ual average  prolongation  of  life  is  more  prob- 
ably due  to  the  very  great  reduction  in  in- 
fant mortality  and  in  deaths  from  infectious 
and  communicable  diseases. 

The  wear  and  tear  on  the  human  organism 
in  our  modem  way  of  living  is  excessive. 
Hard  work,  worry,  and  high  living  all  pre- 
dispose to  degenerative  changes  in  the  arte- 
ries and  so  bring  on  premature  old  age. 

We  have  tried  to  emphasize  this  by  laying 
stress  on  the  prevention  of  arteriosclerosis 
rather  than  on  the  treatment  of  the  fully  de- 
veloped disease. 

No  bibliography  is  given  inasmuch  as  this 
is  not  intended  as  a  reference  book  but  rather 
as  a  guide  to  a  better  appreciation  and  imder- 
standing  of  a  most  important  subject.  It 
has  been  difficult  to  keep  from  wandering 
off  into  full  discussions  of  conditions  incident 
to  and  accompanied  by  arteriosclerosis ;  but, 
in  order  to  be  clear  in  our  statements  and 
complete  in  our  descriptions,  we  have  had 

VI 


to  invade  the  fields  of  heart  disease,  kidney- 
disease,  brain  disease,  etc.  We  trust,  however, 
that  these  excursions  will  serve  to  show  how  in- 
timately disease  of  the  arteries  is  bound  up  with 
diseases  of  all  the  organs  and  tissues  of  the 
body. 

Some  authors  have  been  named  when 
their  opinions  have  been  given.  Thanks 
are  extended  also  to  many  others  to  whom 
the  writer  is  indebted  but  of  whom  no  indi- 
vidual mention  has  been  made. 

The  writer  also  takes  this  opportunity  of 
expressing  his  appreciation  of  the  kindness 
of  Dr.  D.  If.  Harris,  who  took  the  microphoto- 
graphs,  and  to  the  publishers  for  their  un- 
failing courtesy  and  consideration. 

L.  M.  WARFIELD. 
St.  Louis,  Mo.,  August,  1908. 


VII 


CONTENTS. 

PAGE 

Introduction xiii 

Chapter  I.  Anatomy  -  _  .  i 
Chapter  II.  Physiology  of  the  Circu- 
lation— Blood  Pressure  -  9 
Chapter  III.  Pathology  -  -  -  18 
Chapter  IV.  Etiology  .  -  .  41 
Chapter  V.        Symptoms  and  Physical 

Signs  -        -        -        -  55 
Chapter  VI.      Symptoms  and  Physical 

Signs  (cont.)  -  -  71 
Chapter  VII.  Diagnosis  and  Differen- 
tial Diagnosis  -  -  97 
Chapter  VIII.  Prognosis  -  -  -  no 
Chapter  IX.  Prophylaxis  -  -  -  119 
Chapter  X.  Treatment.  -  -  -  128 
Chapter  XI.  Practical  Suggestions.  -  158 
Index 167 


IX 


INDEX  TO  ILI.USTRATIONS. 

Page 
Fig.  I.     Arteriosclerosis  of  the  Thoracic 

and  Abdominal  Aorta        ....    Frontispiece 

Fig.  II.     Normal  Aorta 2 

Fig.  III.  Cross-section  of  a  large  artery  6 
Fig.  IV.  Convenient  sphygmomanometer  12 
Fig.  V.     Nodular  Sclerosis  of  the  Coronary 

Artery 28 

Fig.  VI.  Cross-section  of  a  small  artery 
in  the  Mesentry 34 

Fig.  VII.  Enormous  Hypertrophy  of 
Left   Ventricle 58 

Fig.  VIII.  Aortic  incompetence  with  Hy- 
pertrophy and  dilatation  of  Left  Ventricle    .     74 


XI 


INTRODUCTION. 

There  is  a  despotism  to  which  the  greater 
part  of  mankind  is  enslaved,  a  despotism  as 
absolute  in  the  republic  as  in  the  autocracy 
— ^the  tyranny  of  words.  The  thought  or 
fancy,  unexpressed,  may  have  its  passing 
influence;  expressed,  the  mere  sound  of  our 
own  voice  exercises  upon  us  a  subtile  influence 
which,  as  it  were,  drives  home  the  idea,  while 
repetition  fastens  upon  us  an  impression 
which,  before  we  are  aware  of  it,  has  become 
a  conviction — a  part  of  ourselves. 

A  term  which  strikes  the  popular  ear 
becomes  soon  associated,  in  the  mind  of  the 
average  individual,  with  an  idea  or  a  picture 
which  may  vary  greatly  from  that  of  his 
neighbor,  and  more  yet  from  the  truth.  Never- 
theless time  and  repetition  fix  the  idea  until 
'tis  difficult  to  realize  that  the  word  has  not 
to  everyone  the  same  constant  and  sharply 
defined  signification. 

The  prevalence  of  such  popular  words  and 
expressions  in  medicine  is  familiar  to  all. 

XIII 


These  vary  greatly  in  character  and  origin. 
Those  of  older  years  were  usually  expressions 
intended  to  describe  certain  groups  of  clinical 
symptoms  and  were  based  largely  on  purely 
hypothetical  considerations.  These  terms 
must,  of  necessity,  have  been  rather  indefinite 
and  uncertain  in  their  application  even  among 
the  medical  profession,  and  much  more  so 
among  the  general  public.  Such  is  that 
commonest  and  most  detestable  of  words 
which  means  everything  to  everybody  and 
nothing  under  the  sun  in  itself,  "Biliousness. ' ' 
Such  has  been  the  term  "Malaria"  in  its 
popular  sense.  Such  is,  often  enough,  the  all 
too  popular  word  "Rheumatism. ' '  In  more 
modem  times,  with  the  development  of 
knowledge  of  pathological  anatomy  and 
physiology,  more  accurate  terms  have  come 
into  medicine,  some  based  on  anatomical, 
some  on  physiological  changes.  Many  of 
these  terms  have  also  passed  over  into 
popular  usage.  And  while,  originally,  they 
designated  specific  anatomical  conditions  or 
physiological  processes,  the  uninstructed 
public  associate  them  naturally  with  groups 
of  symptoms,  and  form  many  and  varied 

XIV 


ideas  as  to  their  significance.     But  to  each 
individual  the  words  mean  something. 

All  this  has  too  often  its  repercussion  on 
the  physician  who,  in  order  to  satisfy  his 
patients,  who  demand  a  name  for  the  symptoms 
from  which  they  suffer,  is  led,  almost  uncon- 
sciously, to  use  a  specific  term  in  a  general 
way  to  cover  a  variety  of  conditions  in  which 
perhaps  the  exact  diagnosis  may  not  be  wholly 
clear,  until,  by  force  of  habit  and  repetition, 
he  finds  a  certain  satisfaction  in  hiding 
behind  an  empty  term,  and  becomes  himself 
a  victim  of  the  tyranny  of  words.  What  an 
array  of  pathological  processes  have  been 
dismissed  under  the  specific  diagnosis  of 
'  'gastritis  "  or  '  'neuritis ' ' ! 

The  study  of  those  changes  in  the  blood 
vessels,  hyperplastic,  degenerative,  or  inflam- 
matory which  are  the  inheritance  of  advancing 
years,  and  have  been  so  aptly  called  "the 
rust  of  life  " ,  is  not  new.  The  term  "Arterio- 
sclerosis ' '  was  used  anatomically  by  Lobstein 
three  quarters  of  a  century  ago,  and  the 
relations  of  arterial  change  to  visceral  disease 
have  long  been  a  fertile  field  for  speculation 
and  study.  But  the  popularization  of  the  term 
"Arteriosclerosis"  from  a  clinical  standpoint 

XV 


is  relatively  recent.  In  later  years,  however, 
it  has  definitely  caught  the  popular  ear;  it 
figures  in  the  newspapers  as  a  "new  disease; ' ' 
it  means  something  to  each  member  of  the 
public;  it  is  a  diagnosis  satisfying  to  the 
anxious  friends  of  the  patient.  And,  too 
often,  the  general  diagnosis  "Arteriosclerosis ' ' 
has  come  to  satisfy  the  physician  himself  who, 
without  finding  a  definite  explanation  of  the 
obscure  symptoms  of  his  patient,  rests  on  his 
oars  with  the  constatation  of  the  tortuous 
temporal  or  the  palpable  radial  of  the  sufferer. 
The  term  "Arteriosclerosis ' '  is  fast  coming  to 
take  a  place  near  the  throne  once  occupied  by 
"Malaria";  it  is  becoming  a  dangerous  word. 
Great  as  is  the  importance  of  arterial 
changes  in  relation  to  many  of  the  ills  to 
which  flesh  is  heir,  and  numerous  as  have 
been  the  anatomical,  clinical  and  experimental 
researches  concerning  this  subject,  it  must 
be  acknowledged  that  there  is  much  yet  to  be 
learned  with  regard  to  the  etiology,  the 
manner  of  development,  the  nature  of  the 
changes  in  different  parts  of  the  arterial  tree, 
their  relation  to  variations  in  blood  pressure 
and  to  visceral  disease  as  well  as  concerning 
the  relations  of  peripheral  to  central  changes ; 

XVI 


and  there  are  still  wide  differences  of  opinion 
as  to  the  interpretation  of  some  of  the  obser- 
vations which  have  been  made. 

In  view  therefore  of  these  considerations 
as  well  as  of  the  widespread  and  indiscriminate 
popular  use  of  the  term  "Arteriosclerosis," 
the  time  would  seem  to  be  peculiarly  fitting 
for  the  publication  of  a  brief  and  practical 
consideration  of  the  present  state  of  our 
knowledge  concerning  the  nature  and  clinical 
bearings  of  arterial  disease  such  as  that  which 
my  friend  Dr.  Warfield  seeks  to  set  forth. 

There  can  be  no  doubt  that  we  Americans 
are  prone  to  waste  our  energies.  We  do  not 
know  how  to  rest  or  to  conserve  our  strength ; 
and  it  is  probably  true,  as  Dr.  Warfield 
suggests,  that  the  wear  and  tear  of  this 
feverish  and  unreasoning  activity  leaves,  too 
often,  an  early  mark  on  the  cardio-vascular 
system. 

It  should,  as  he  has  said,  be  the  earnest 
endeavor  of  the  physician  to  prevent  the 
premature  development  of  these  vital  changes 
rather  than  to  seek  to  alleviate  symptoms 
after  irreparable  damage  has  been  done. 

Wii^iyiAM  Sydney  Thayer. 
Baddeck,  Cape  Breton,  26  August,  1908. 

XVII 


CHAPTER  I. 

ANATOMY. 

With  the  increased  complexity  of  our  mod- 
ern life,  comes  increased  wear  and  tear  on 
the  human  organism.  This  is  most  often 
revealed  in  the  very  commonly  seen  arterial 
disease  which  may  develop  in  persons  much 
under  middle  age.  The  old  adage  that  "A 
man  is  as  old  as  his  arteries"  is  even 
more  true  today,  if  possible,  than  when  it 
was  first  said. 

Arteriosclerosis  is  not  universally  consid- 
ered to  be  a  disease  sui  generis;  some  authors 
would  rather  call  it  a  symptom  or  a  group  of 
symptoms  which,  however,  are  not  specific 
enough  to  warrant  their  collection  into  a 
definite  disease.  We  shall,  however,  con- 
sider arteriosclerosis  as  a  disease  rather  than 
as  a  symptom  group  for,  from  a  clinical  stand- 
point, there  is  much  in  favor  of  regarding  it 
as  an  entity. 

Definition — ^Arteriosclerosis  (Arteriocap- 
illary  fibrosis)  may  be  defined  as  a  suba- 
cute and  chronic  disease  of  the  arteries,  char- 


2  Arteriosclerosis 

acterized  anatomically  by  increased  thick- 
ness of  the  walls  of  the  blood  vessels,  the  in- 
itial lesion  being  for  the  most  part  in  the  mid- 
dle (muscular)  coat,  leading  not  infrequently 
to  calcification  of  this  coat  and  to  the  forma- 
tion of  minute  aneurysms  along  the  vessels. 
The  term  arterio-capillary  fibrosis  undoubt- 
edly has  a  broader  meaning.  Almost  with- 
out exception  the  capillaries  are  involved  in 
the  morbid  process,  and  even  the  veins  may 
be  markedly  thickened.  Under  such  cir- 
cumstances, it  is  proper  to  speak  of  vascular 
sclerosis  or   angiosclerosis. 

A  few  brief  reminders  of  the  anatomy  of 
the  arteries  will  not  be  out  of  place  here.  For 
the  clear  comprehension  of  the  disease  under 
discussion,  it  is  necessary  to  keep  in  mind  the 
essential  histological  differences  between  the 
aorta  and  the  larger  and  smaller  branches  of 
the  arterial  tree. 

The  vascular  system,  as  a  whole,  is  often 
referred  to  as  a  central  pump  with  a  series  of 
closed  tubes  that  branch  widely,  and,  col- 
lecting again,  converge  into  vessels  of  the 
same  area  as  at  the  beginning.  While  this 
is  a  rough  illustration,  it  is  useful  but  natur- 


FIG.  II. 


Fig.  II.  Normal  aorta.  Compare  with  Figure  I.  Note 
the  perfectly  smooth,  glossy  appearance  of  the  intima. 
The  openings  of  all  the  intercostal  arteries  are  distinctly 
seen.  In  the  recent  state  this  artery  was  highly  elastic, 
capable  of  much  stretching  both  transversely  and  long- 
itudinally. 


Anatomy  3 

ally  does  not  take  into  account  the  vital  forces 
that  control  every  part  of  the  system. 

Generai.  Structure  of  The  Arteries  — 
The  essential  portion  of  any  blood  vessel  is 
the  endothelial  tube  composed  of  flat  cells 
cemented  together  by  intercellular  substance 
and  having  no  stomata  between  the  cells. 
This  tube  is  reinforced  in  different  ways  by 
connective  tissue,  smooth  muscle  fibres  and 
fibro-elastic  tissue.  Although  the  gradations 
from  the  larger  to  the  smaller  arteries  and 
from  these  to  the  capillaries  and  veins  are 
almost  insensible,  yet  particular  arteries  pre- 
sent structural  characters  sufficiently  marked 
to  admit  of  histological  differentiation. 

The  whole  vascular  system,  including  the 
heart,  has  an  endothelial  lining  which  may 
constitute  a  distinct  inner  coat,  the  tunica 
intima,  or  may  be  without  coverings  as  in 
the  case  of  the  capillaries.  The  intima 
(Fig.  III.)  consists  typically  of  endothelium 
reinforced  by  a  variable  amount  of  fibro- 
elastic  tissue  in  which  the  elastic  fibres  pre- 
dominate. The  tunica  media  is  composed 
of  intermingled  bundles  of  elastic  tissue, 
smooth  muscle  fibres,  and  some  fibrous  tis- 


4  Arteriosclerosis 

sue.  The  adventitia  or  outer  coat  is  exceed- 
ingly tough.  It  is  usually  thinner  than  the 
media  and  is  composed  of  fibro-elastic  tissue. 
This  division  into  three  coats  is,  however, 
somewhat  arbitrary,  as  in  the  larger  arteries, 
particularly,  it  is  difficult  to  discover  any 
distinct  separation  into  layers. 

The  muscular  layer  varies  from  single  scat- 
tered cells,  in  the  arterioles,  to  bands  of  fibres 
making  up  the  body  of  the  vessel  in  the  me- 
dium sized  arteries  and  veins. 

There  is  elastic  tissue  in  all  but  the  smallest 
arteries,  and  it  is  also  found  in  some  veins. 
It  varies  in  amount  from  a  loose  network  to 
dense  membranes.  In  the  intima  of  the 
larger  arteries  the  elastic  tissue  occurs  as 
sheets  which  under  the  microscope  appear 
perforated  and  pitted,  the  so-called  fenes- 
trated membrane  of  Henle. 

The  nutrient  vessels  of  the  arteries  and 
veins,  the  vasa  vasorum,  are  present  in  all 
the  vessels  except  those  less  than  one  milli- 
meter in  diameter.  The  vasa  vasorum  course 
in  the  external  coat  and  send  capillaries  into 
the  media.  Lymphatics  and  nerves  are  also 
found  in  the  vascular  walls. 


Anatomy  5 

Arteries — ^The  structure  of  the  arteries 
varies  notably,  depending  upon  the  size  of  the 
vessel.  In  a  cross  section  of  the  radial  artery, 
one  sees  a  wavy  outline  of  intima,  caused  by 
the  endothelium  following  the  corrugations 
of  the  elastica.  The  endothelium  is  seen  as 
a  delicate  line  in  which  a  few  nuclei  are  visi- 
ble. The  media  is  comparatively  thick,  and 
is  composed  of  muscle  cells,  arranged  in  flat 
.bundles,  and  plates  of  elastic  tissue.  Between 
the  media  and  the  externa  the  elastic  tissue 
is  somewhat  condensed  to  form  the  external 
elastic  membrane.  The  adventitia  varies 
much  in  thickness,  being  better  developed 
in  the  medium  sized  than  in  the  large  arte- 
ries. It  is  composed  of  fibrous  tissue  mixed 
with  elastic  fibres. 

"Followed  towards  the  capillaries,  the 
coats  of  the  artery  gradually  diminish  in 
thickness,  the  endothelium  resting  directly 
upon  the  internal  elastic  membrane  so  long 
as  the  latter  persists,  and  afterwards  on  the 
rapidly  attenuating  media.  The  elastica  be- 
comes progressively  reduced  until  it  entirely 
disappears  from  the  middle  coat,  which  then 
becomes  a  purely  muscular  tunic  and,  before 


6  Atreriosderosis. 

the  capillary  is  reached,  is  reduced  to  a  single 
layer  of  muscle  cells.  In  the  precapillary- 
arterioles  the  muscle  no  longer  forms  a  con- 
tinuous layer,  but  is  represented  by  groups  of 
fibre-cells  that  partially  wrap  around  the  vessel, 
and  at  last  are  replaced  by  isolated  elements. 
After  the  disappearance  of  the  muscle-cells, 
the  bloodvessel  has  become  a  true  capillary. 
The  adventitia  shares  in  the  general  reduc- 
tion, arid  gradually  diminishes  in  thickness 
until,  in  the  smallest  arteries,  it  consists  of 
only  a  few  fibro-elastic  strands  outside  the 
muscle-cells"   (Piersol's  Anatomy). 

The  large  arteries  differ  from  those  of  me- 
dium size  mainly  in  the  fact  that  there  is  no 
sharp  line  of  demarcation  between  the  intima 
and  the  media.  There  is  also  much  more 
elastic  tissue,  distributed  in  firm  bundles 
throughout  the  media,  and  there  are  fewer 
muscle  fibres,  giving  a  more  compact  appear- 
ance to  the  artery  as  seen  in  cross  section. 
This  predominance  of  elastic  tissue  permits 
of  great  distension  by  the  blood  forced  into 
the  artery  at  every  heartbeat,  the  calibre  of 
the  tube  being  less  markedly  imder  the  con- 
trol of  the  vasomotor  nerves  than  is  the  case 


FIG.  HI. 


Fig.  III.  Cross  section  of  a  large  artery  showing  the 
division  into  the  three  coats;  intima,  media,  adventitia. 
The  intima  is  a  thin  Une  composed  of  endothelial  cells. 
The  wavy  elastic  lamina  is  well  seen.  The  thick  middle 
coat  is  composed  of  muscle  fibres  and  fibro-elastic  tissue. 
The  loose  tissue  on  the  outer  (lower  portion  of  cut)  side 
of  the  media  is  the  adventitia. 


Anatomy  7 

in  the  small  arteries  where  the  muscle  tissue 
is  relatively  more  developed.  The  adventitia 
of  the  large  arteries  is  strong  and  firm,  and 
is  made  up  of  interlacing  fibro-elastic  tissue 
of  which  some  of  the  bundles  are  arranged 
longitudinally. 

Veins — The  walls  of  the  veins  are  thinner 
than  those  of  the  arteries ;  they  contain  much 
less  elastic  and  muscular  tissue,  and  are, 
therefore,  more  flaccid  and  less  contractile. 
Many  veins,  particularly  those  of  the  ex- 
tremities, are  provided  with  cuplike  valves 
opening  towards  the  heart.  These  valves, 
when  closed,  prevent  the  return  of  the  blood 
to  the  periphery  and  distribute  the  static 
pressure  of  the  blood  column.  The  bulgings 
caused  by  the  valves  may  be  seen  in  the  super- 
ficial veins  of  the  arm  and  leg.  There  are 
no  valves  in  the  veins  of  the  neck  where  there 
is  no  necessity  for  such  a  protective  mechan- 
ism, gravity  sufficing  to  drain  the  venous 
blood  from  the  cranial  cavity. 

Capii^laries — ^These  are  endothelial  tubes 
in  the  substance  of  the  organs,  the  tissue  of 
the  organ  giving  them  the  necessary  support. 
They  are  the  final  subdivisions  of  the  blood- 


8  Arterioslcerosis 

vessels,  and  the  vast  capillary  area  offers  the 
greatest  amount  of  resistance  to  the  blood 
flow,  and  thus  serves  to  slow  the  blood  stream 
and  allow  time  for  nutritive  substances  or 
waste  products  to  pass  from  and  to  the  blood, 
Usually  the  capillaries  are  arranged  in  the 
form  of  a  net  work,  the  channels  in  any  one 
tissue  being  of  nearly  uniform  size,  and  the 
closeness  of  the  mesh  depending  upon  the  or- 
gan. Thus,  in  the  lung,  the  mesh  work  is 
closest ;  in  organs  of  great  functional  activity, 
as  in  the  kidneys,  the  thyroid,  the  hver,etc., 
there  is  an  enormous  capillary  net  work. 

The  capillaries  have  no  nerve  supply,  but 
are  flushed  or  emptied  entirely  by  the  dilatation 
or  contraction  of  the  small  arteries.  The 
capillary  resistance  really  depends  to  a  great 
extent  on  the  behaviour  of  the  very  small 
arteries  in  which  are  a  few  muscle  cells  suf- 
ficient to  close  the  lumen  of  the  vessel  when 
excessively  stimulated  and  thus  to  shut  off  a 
capillary  area.  When  this  happens  to  great 
numbers  of  the  smallest  arteries,  parts  of  or- 
gans or  whole  organs  maybe  rendered  anemic, 
and,  in  the  case  of  the  fingers  or  toes,  small 
portions  may  actually  become  gangrenous. 


CHAPTER  II. 

PHYSIOLOGY  OF  THE  CIRCULATION. 
BLOOD  PRESSURE. 

No  attempt  will  be  made  to  give  more 
than  a  very  brief  outline  of  the  chief  points 
in  the  physiology  of  the  circulation  that  have 
a  special  bearing  on  the  disease  under  dis- 
cussion. A  complete  understanding  of  the 
physiology  of  the  heart  and  bloodvessels 
facilitates  the  comprehension  of  many  of 
the  morbid  processes  that  are  found  in  arte- 
riosclerosis and  explains  why  it  is  that  not 
always  do  we  have  defects  that  a  priori  might 
be  expected  to  follow  certain  causes. 

"The  heart  and  the  blood  vessels  form  a 
closed  vascular  system  containing  a  certain 
amount  of  blood.  This  blood  is  kept  in 
endless  circulation  mainly  by  the  force  of 
the  muscular  contraction  of  the  heart.  But 
the  bed  through  which  it  flows  varies  greatly 
in  width  at  different  parts  of  the  circuit,  and 
the  resistance  offered  to  the  moving  blood 


10  Arteriosclerosis 

is  very  much  greater  in  the  capillaries  than 
in  the  large  vessels."  (Howell,  Textbook 
on  Physiology.) 

The  velocity  varies  greatly  in  different 
parts  of  the  circulation.  In  the  arteries  it 
changes  with  every  heart  beat.  As  the  bed 
widens  the  flow  is  necessarily  slower,  until, 
in  the  enormous  capillary  area,  the  flow  has 
become  even  and  slow,  and  increases  as  the 
blood  is  collected  into  the  venules,  until  at  the 
venous  openings  of  the  right  auricle  it  is  al- 
most as  rapid  as  at  the  aorta. 

Innumerable  factors  influence  the  rate 
and  amount  of  the  flow  to  any  part  or  parts. 
Given  a  fixed  amount  of  fluid  that  completes 
a  circle  in  a  certain  time,  any  change  in  any 
part  of  the  circle  necessarily  has  its  opposite 
effect  elsewhere  in  the  circle  provided  we  as- 
sume that  the  force  and  rate  of  the  heart 
beat  remain  the  same.  Thus  contraction 
of  all  the  vessels  in  the  splanchnic  area  cuts 
off  an  enormous  portion  of  the  circle.  Now, 
if  the  blood  is  to  make  the  circuit  in  the  same 
time  as  before  the  contraction,  then  vessels 
elsewhere  must  dilate  to  a  corresponding  de- 
gree.    Suppose  now  that  there  were  some 


Physiology  of  the  Circulation  1 1 

substance  in  the  circulation  that  acted  par- 
ticularly on  the  musculature  of  the  splanch- 
nic vessels  causing  them  to  contract  and  to 
a  lesser  extent  on  the  other  arteries,  then  an 
increased  resistance  would  result  which  could 
be  overcome  only  by  more  force  exerted  on 
the  part  of  the  heart. 

At  every  systole  from  50  to  100  cc.  of  blood 
are  thrown  into  an  already  filled  aorta .  Ther  e 
is  thus  70-80  times  a  minute  forcible  stretch- 
ing of  the  arch  and  the  thoracic  aorta.  In 
order  to  accommodate  this  extra  blood  these 
structures  must  expand.  After  the  closure 
of  the  aortic  valves  the  column  of  blood  is 
kept  at  a  considerable  pressure  by  the  com- 
pression of  the  highly  elastic  aorta.  At  the 
top  of  the  arch  three  large  vessels  are  given 
off,  the  innominate,  the  left  carotid,  and  the 
left  subclavian.  These  to  some  extent  take 
up  a  portion  of  the  strain.  No  other  large 
vessels  are  given  off  until  below  the  diaphragm. 
It  is  thus  seen  why  it  is  that  the  thoracic 
aorta  is  more  apt  to  be  the  seat  of  disease 
than  any  part  of  the  vascular  system. 

In  order  that  the  blood  may  course  through 
the  vascular  system  a  certain  head  of  pres- 


12  Arteriosclerosis 

sure  must  be  maintained.  As  the  heart  con- 
tracts, the  pressure  is  suddenly  raised  and 
the  pulse  wave  is  transmitted  towards  the 
periphery.  This  pressure  is  known  as  the 
maximum  or  systohc  pressure.  It  is,  of 
Course,  highest  at  the  heart.  In  the  brachial 
artery  in  man,  where  the  pressure  is  usually 
measured,  it  amoimts  to  lOo  to  130  mm.  of 
mercury.  It  is  lower  in  children  and  higher 
in  old  people  as  a  general  rule,  to  which  there 
are  numerous  exceptions.  The  minimum 
pressure  in  the  artery,  i.  e.,  the  pressiure  at 
the  end  of  diastole,  is  known  as  the  diastolic 
pressiu'e.  The  difference  between  these  two 
pressiu-es  is  known  as  the  pulse  pressiue,  and 
meastues  normally  in  an  adult  in  the  brachial 
artery  about  45  to  48  mm.  of  mercury.  This 
represents  to  a  great  extent  the  elastic  force 
of  the  aorta  which  diuring  diastole  keeps  the 
blood  flowing  and  maintains  the  pressiue. 

Several  instruments  have  been  devised  to 
measiu*e  the  maximum  blood  pressure  in  man. 
Instruments  have  also  been  made  to  measure 
the  minimum  pressure  but  they  are  too  com- 
plicated for  general  use.  Cook's  modification 
of  the  Riva-Rocci  instrument  with  the  9  or 


FIG.  IV. 


Fig.  IV.  A  convenient  sphygmomanometer.  A,  stand 
made  of  thin  board  fitted  securely  to  a  heavy  base  4x4x3^ 
in.;  B,  scale  graduated  in  centimeters  and  millimeters 
from  1  to  15;  C,  the  U-tube  of  heavy  glass  2  mm.  in  diam- 
eter, the  mercury  shown  standing  at  zero  on  the  scale; 
D,  short  outlet  tube  with  clamp;  E,  9  cm.  arm  band  of 
rubber  encased  in  heavy  canvass,  the  hooks  and  eyes  sewn 
on  the  canvass  so  that  the  band  may  be  snugly  fitted 
around  the  arm  above  the  elbow;  F,  a  double  bulb  syringe 
for  inflating  the  arm  band.  The  arm  band  and  tube  con- 
taining the  mercury  have  free  air  connection  so  that  when 
the  arm  is  compressed  by  the  air  forced  into  the  arm  band 
the  mercury  rises  in  the  tube.  With  a  finger  on  the  pulse 
of  the  subject  the  syringe  is  compressed  until  the  pulse 
disappears.  By  cautiously  letting  out  air  through  the 
clamp  D,  the  point  on  the  scale  is  noted  when  the  pulse 
first  is  felt.  Several  readings  are  to  be  made  and  the  aver- 
age taken.  This  gives  the  systolic  pressure.  The  dias- 
tolic pressure  cannot  be  determined  with  any  degree  of 
accuracy  with  any  but  the  most  elaborate  instruments. 
The  distance  that  the  mercury  rises  in  the  left  arm  of  the 
tube  is  doubled  in  order  to  get  the  whole  reading,  for  the 
mercury  in  the  tube  on  the  right  is  depressed  to  the  same 
extent  as  it  is  elevated  on  the  left.  This  instrument  en- 
ables one  to  read  pressures  of  300  mm.  of  Hg. 


Physiology  of  the  Circulation  13 

12  cm.  arm  band,  Janeway's  portable  in- 
strument or  the  Stanton  instrument  are  all 
used.  The  principle  upon  which  all  depend 
is  the  compression  of  the  brachial  artery  by 
means  of  air  forced  into  a  band,  resulting  in 
the  obliteration  of  the  pulse  at  the  wrist. 
Mercury  is  forced  into  an  upright,  or  U-tube, 
and  just  at  the  time  when  the  pulse  at  the 
wrist  disappears,  the  reading  is  made.  This 
is  the  systolic  pressure.  If  now  air  is  re- 
leased and  the  point  noted  where  the  maxi- 
mum oscillation  of  the  mercury  occurs,  one 
may  read  approximately  the  disastolic  pres- 
sure. The  difference  between  these  two  read- 
ings is,  of  course,  the  pulse  pressure. 

An  excellent  and  reasonable  instrument 
is  shown  in  the  illustration   (Fig.  IV). 

Physiologically  there  are  wide  fluctuations 
in  the  blood  pressure.  It  is  least  lying  down 
and  greatest  standing  up.  Sleep,  exercise, 
food,  drink,  psychic  factors,  etc.,  may  alter 
the  blood  pressure  gradually  or  suddenly. 
However,  increase  of  pressure,  unless  patho- 
logical, is  not  maintained  after  the  particular 
stimulus  has  ceased  to  act. 


14  Arteriosclerosis 

Undoubtedly  the  greatest  blood  pressure 
values  are  to  be  seen  in  cases  of  chronic  in- 
terstitial nephritis  where  the  systolic  pressure 
reaches  270  mm.  of  mercury  or  even  higher. 
Not  all  diseases  of  the  kidney,  however,  cause 
increased  blood  pressure.  It  is  frequently 
absent  in  the  toxic  nephritis  cases  and  in 
those  caused  by  certain  of  the  infectious  dis- 
eases. However,  in  primary  acute  Bright 's 
disease,  which  is  probably  infectious  in  char- 
acter, and  in  the  nephritis  secondary  to  scar- 
let fever,  there  is  practically  always  an  in- 
crease in  the  arterial  pressure.  This  rise  may 
amount  to  fifty  millimeters  of  mercury  within 
forty-eight  hours  of  the  onset  of  the  disease. 

Certain  forms  of  arteriosclerosis  cause  a 
permanent  increase  in  blood  pressure  and  are 
accompanied  by  heart  hypertrophy.  Such 
are  especially  cases  of  sclerosis  of  the  first 
part  of  the  aorta  and  extensive  sclerosis  of 
the  splanchnic  vessels.  In  uncomplicated 
arteriosclerosis,  only  a  small  proportion  of 
patients  show  increased  blood  pressure.  When 
the  elasticity  of  the  arteries  is  diminished, 
they  ofi'er  a  greater  resistance  to  dilating  for- 
ces, but  once  having  been  dilated,  they  do 


Physiology  of  the  Circulation  15 

not  so  easily  recover  their  original  size.  The 
rigidity  of  certain  areas  may  be  neutralized 
by  dilatation  of  other  areas.  But  the  splanch- 
nic arteries  are  of  such  paramount  import- 
ance in  the  regulation  of  the  peripheral  resist- 
ance that  disease  in  them  renders  it  difficult 
or  impossible  for  dilatation  in  other  parts  of 
the  body  to  be  sufficient  to  compensate  for 
the  splanchnic  contraction.    (Fig.  VI). 

Elliott  recently  in  an  interesting  compari- 
son of  the  blood  pressure  in  pure  arterioscle- 
rosis and  in  chronic  nephritis  arrived  at  the 
following  conclusions:  (i)  The  ordinary  clin- 
ical type  of  arteriosclerosis  is  not  necessarily 
accompanied  by  high  blood  pressure;  (2) 
Where  high  blood  pressure  is  met  with  in  arte- 
riosclerosis, it  points  to  the  existence  either  of 
associated  renal  disease,  or  of  sclerosis  of  the 
splanchnic  vessels  and  of  the  aorta  above  the 
diaphragm — or  both;  (3)  If  we  can  exclude 
the  renal  disease  (chronic),  splanchnic  or 
aortic  sclerosis  is  to  be  suspected. 

If  it  were  not  for  the  so-called  tone  of  the 
whole  vascular  area  the  heart  could  not  main- 
tain the  circulation.  This  tone  is  maintained 
by  the  contraction  of  the  involuntary  muscle 


16  Arteriosclerosis 

in  the  vessels.  With  the  exception  of  the 
arteries  of  the  brain  and  of  the  lungs,  there 
are  both  vasoconstrictor  and  vasodilator 
fibres  from  the  sympathetic  nervous  system 
to  the  smooth  muscle  fibres  of  the  arteries. 
The  splanchnic  area  is  relatively  poorly  sup- 
plied with  dilator  fibres.  The  continuous 
constrictor  impulses  sent  out  from  the  sym- 
pathetic ganglia  along  the  dorsal  spine  to 
the  arteries  keeps  the  vessels  in  a  state  of  con- 
striction sufficient  to  offer  enough  resistance 
to  the  blood  flow  to  facilitate  the  work  of  the 
heart  without  placing,  for  any  prolonged 
period,  a  great  strain  on  it. 

It  is,  therefore,  conceivable  that  an  in- 
crease in  blood  pressure  may  come  about  in 
two  ways:  (i)  by  stimulation  of  the  constric- 
tor centre  (or  centres?) ;  (2)  by  direct  action 
on  the  muscle  cells  in  the  arterial  walls.  It 
is  believed  that  the  active  principle  from  the 
medulla  of  the  adrenal  gland,  adrenalin,  is 
responsible  for  the  maintenance  of  the  arte- 
rial tone.  It  has  been  found  that  at  various 
places  in  the  body  there  are  collections  of 
cells  known  as  chromaffin  cells,  which  ap- 
parently have  an  internal  secretion  analogous 


Physiology  of  the  Circulation.  17 

to,  if  not  the  same  as,  the  active  principle  of 
the  adrenal  gland.  A  group  of  these  cells 
discovered  in  the  heart,  has  been  found  to  be 
much  hypertrophied  in  a  case  of  chronic  in- 
terstitial nephritis  accompanied  with  in- 
creased blood  pressure  and  heart  hypertrophy. 

Clinically,  we  know  that  adrenalin  causes 
a  rise  in  the  bloodpressure.  Experimentally, 
as  we  shall  discuss  later,  adrenalin  not  only 
is  able  to  cause  a  rise  in  blood  pressure  but 
also  a  degeneration  of  the  muscle  layer  with 
consequent  production  of  lesions  resembling 
to  some  extent  those  of  arteriosclerosis  in 
man. 

While  it  must  not  be  forgotten  that,  given 
an  equal  peripheral  resistance,  a  rapid  heart 
will  cause  the  blood  pressure  to  rise,  never- 
theless this  condition  usually  does  not  last 
long.  Practically  all  cases  of  permanent  high 
tension  are  due  to  increase  of  the  peripheral 
resistance. 


CHAPTER   III. 

PATHOLOGY. 

The  whole  subject  of  the  pathology  of  ar- 
teriosclerosis has  been  much  enriched  by  the 
study  of  the  experimental  lesions  produced 
by  various  drugs  and  micro-organisms  upon 
the  aortas  of  rabbits.  Simple  atheroma 
must  not  be  confused  with  the  lesions  of  ar- 
teriosclerosis. The  small  whitish  or  yellow- 
ish plaques  so  frequently  seen  on  the  aorta  and 
its  branches,  may  occur  at  any  age,  and  have 
seemingly  no  great  significance.  Such  places 
may  grow  to  the  size  of  a  dime  or  more,  and 
even  become  eroded.  They  represent  fatty 
degeneration  of  the  superficial  endothelium 
that  at  times  has  no  demonstrable  cause,  at 
times  follows  in  the  course  of  various  diseases, 
and  undoubtedly  is  due  to  disturbances  of 
nutrition  in  the  intima.  Except  for  "the 
danger  of  clot  formation  on  the  uneven  or 
eroded  spot,  these  places  are  of  no  especial 
significance,  and  are  not  to  be  confused  with 
the  atheroma  of  nodular  sclerosis. 


Pathology.  19 

The  lesions  of  true  arteriosclerosis  are  of 
a  different  character.  It  has  been  customary 
to  differentiate  three  types,  (i)  the  focal  or 
nodular;  (2)  the  diffuse;  (3)  the  senile.  It 
seems  of  no  great  value  to  make  a  separate 
division  of  the  senile  form  but  for  conveni- 
ence of  description  it  will  be  done.  The  re- 
trogressive changes  of  advancing  years  can- 
not be  rightly  termed  disease,  and  the  fact 
even  that  a  man  of  forty  years  may  have  the 
hard  arteries  of  a  man  of  eighty  may  mean 
only  that  the  tissue  of  the  former  was  poor, 
the  tubing  wore  out  early.  Our  parents  de- 
termine the  kind  of  tissue  that  we  shall  have 
as  our  inheritance.  The  arteries  are  elastic 
tubes  capable  of  much  stretching  and  abuse. 
In  the  aorta  and  large  branches  there  is  much 
elastic  tissue  and  little  muscle.  When  the 
vessels  reach  the  organs,  they  are  found  to 
be  structurally  changed  in  that  there  is  in  them 
a  relatively  small  amount  of  elastic  tissue  but 
a  great  deal  of  smooth  muscle.  This  is  a 
provision  of  nature  to  increase  or  decrease 
the  supply  at  any  one  point. 

The  aorta  and  the  large  branches  are  dis- 
tributing tubes.     There  is  no  necessity  for 


20  Arteriosclerosis 

great  changes  in  the  capacity  of  the  area.  On 
the  contrary,  the  feed  pipes,  the  actual  irri- 
gators, must  have  some  mechanism  by  which 
they  may  flood  or  curtail  the  supply  of  blood 
to  the  part.  It  is  after  all  in  the  arterioles 
and  smaller  arteries,  those  with  considerable 
muscle  fibre  that  the  lesions  of  arterioscle- 
rosis do  the  most  damage.  A  point  to  be 
emphasized  is  that  the  whole  arterial  system 
is  rarely,  if  ever,  attacked  uniformly.  That 
is,  there  may  be  a  marked  degree  of  sclerosis 
in  the  aorta  and  coronary  arteries  with  very 
little,  if  any,  change  in  the  radials.  On  the 
contrary,  a  few  peripheral  arteries  only  may 
be  the  seat  of  disease.  It  is  not  possible  to 
judge  the  state  of  the  whole  arterial  system 
by  the  stage  of  the  lesion  in  any  one  artery, 
but  on  the  whole  an  undue  thickening  of  the 
radial  indicates  analogous  changes  in  the 
mesenteric  artery  and  the  aorta. 

As  the  body  ages,  certain  changes  take  place 
in  the  arteries  leading  to  thickening  and  in- 
elasticity of  their  walls.  This  is  a  normal 
change,  and  in  estimating  the  palpable  thick- 
ening of  an  artery,  such  as  the  radial,  the  age 
of  the  individual  must  always  be  considered. 


Pathology  21 

Thayer  and  Fabyan  in  an  examination  of 
the  radial  artery  from  birth  to  old  age  found 
that  in  general  the  artery  strengthens  itself 
as  more  strain  is  thrown  upon  it,  bynewelas- 
tica  in  the  intima,  and  connective  tissue  in 
the  media  and  adventitia.  Up  to  the  third 
decade  there  is  only  a  strengthening  of  the 
media  and  adventitia.  During  the  third  and 
fourth  decades  there  is  also  distinct  connective 
tissue  thickening  in  the  intima.  "In  other 
words,  the  strain  has  begun  to  tell  upon  the 
vessel  wall,  and  the  yielding  tube  fortifies  it- 
self by  the  connective  tissue  thickening  of 
the  intima  and  to  a  lesser  extent  of  the  media. " 
By  the  fifth  decade  the  connective  tissue  de- 
posits in  the  intima  are  marked,  there  is  an 
increase  of  fibrous  tissue  upon  the  medial  side 
of  the  intima  and,  in  lesser  degree,  through- 
out the  media.  The  vessel  can  now  be  felt 
as  a  uniform  tube.  "Finally,  in  these  scle- 
rotic vessels,  degenerative  changes  set  in, 
which  are  somewhat  different  from  those 
seen  in  the  larger  arteries,  consisting  as  they 
do,  of  local  areas  of  coagulation  necrosis  with 
calcification,  especially  marked  in  the  deep 
layers  of  the  connective  tissue  thickenings 


22  Arteriosclerosis 

of  the  intima,  and  in  the  muscle  fibres  of  the 
media,    particularly   opposite   these   points. 

These  changes  may go  on  to 

actual  bone  formation."  The  mesenteric 
artery  differs  in  some  respects  from  the  radial, 
but  in  the  main  the  changes  brought  about 
by  age  are  the  same.  Thayer  and  Fabyan 
note  two  striking  points  of  difference:  "(i) 
Calcification  is  apparently  much  less  fre- 
quent than  in  the  radials.  (2)  In  several 
cases  plaques  were  seen  with  fatty  softening 
of  the  deeper  layers  of  the  intima  and  super- 
ficial proliferation — a  picture  which  we  have 
never  seen  in  the  radial." 

In  the  aorta  the  elastic  muscular  intima 
thickens  progressively  with  age.  Scheel  has 
made  very  careful  measurements  of  the  as- 
cending, the  thoracic  and  abdominal  aorta, 
and  the  pulmonary  artery.  He  found  that 
from  birth  to  60  years  the  aorta  became  pro- 
gressively wider  and  lost  its  elasticity.  The 
pulmonary  artery  changed  little  if  at  all  after 
30-40  years  and  where  before  it  was  wider 
than  the  aorta,  it  now  was  found  to  be  smaller. 
In  chronic  nephritis  both  were  widened.  The 
continuous  increase  of  width  and  length  of 


Pathology  23 

the  aorta  stands  in  reverse  relationship  to 
the  elasticity  of  its  walls.  This  is  the  pro- 
cess that  later  leads  to  arteriosclerosis. 

So  far  as  the  anatomical  lesions  in  the  aorta 
and  branches  are  concerned  there  is  much 
uniformity  even  though  the  etiological  factors 
have  been  diverse.  The  only  difference  is 
one  of  extent.  To  Thoma  we  owe  the  first 
careful  work  on  arteriosclerosis.  He  re- 
garded the  lesion  in  arteriosclerosis  as  one  pri- 
marily situated  in  the  media,  a  lack  of  re- 
sistance in  this  coat.  A  rupture  here  caused 
a  local  widening  and  consequently  the  blood 
could  not  be  distributed  evenly  to  the  organ 
which  the  diseased  artery  or  arteries  supplied . 
Moreover,  there  was  danger  of  a  rupture  at 
the  weak  spot  unless  this  spot  were  strength- 
ened and  the  lumen  again  made  its  former 
size.  Nature's  method  of  repair  was  a  hyper- 
trophy of  the  subintimal  connective  tissue 
and  the  formation  of  a  nodule  at  that  point. 
The  thickening  was  compensatory,  resulting 
in  the  establishment  of  the  normal  calibre 
of  the  vessel.  Thoma  showed  that  by  in- 
jecting an  aorta,  the  subject  of  such  changes, 
with  paraffin  at  a  pressure  of  about  i6omm. 


24  Arteriosclerosis 

Hg.,  these  projections  disappeared  and  the 
muscle  bulged  externally.  He  recognized 
the  fact  that  the  character  of  the  artery- 
changed  as  the  years  passed,  and  to  this  form 
he  gave  the  name  primary  arteriosclerosis. 
To  the  group  of  cases  caused  by  various  toxic 
agents,  or  following  peripheral  resistance  and 
consequent  high  pressure,  he  gave  the  name 
secondary  arteriosclerosis.  This  is  a  useful 
division.  Even  in  the  diffuse  form  one  will 
not  find  lesions  of  the  same  grade  everywhere. 
The  sclerosis  is  scattered  all  over  the  system; 
indeed  there  may  be  parts  that  show  no  lesions 
whatever.  Recently  these  experiments  of 
Thoma  have  been  repeated  and  results  ob- 
tained which  are  not  in  accord  with  his  find- 
ings. For  example,  Ophuls  finds  that  stretch- 
ing of  an  aorta  that  has  not  lost  its  elasticity 
will  also  smooth  out  the  atheromatous  plates 
and  nodules,  and,  moreover,  that  careful  ex- 
amination of  cross  sections  made  through  areas 
beneath  the  now  flattened  plates,  fails  to  re- 
veal any  evidence  of  weakness  or  degenera- 
tion of  muscle.  He  attempts  to  explain 
the  discrepancy  between  his  and  Thoma 's 
results  by  supposing  that  Thoma  examined 


Pathology.  25 

late  stages  of  the  process  when  the  media 
was  diseased;  then  it  could  not  be  told  whether 
or  not  the  lesions  in  the  media  were  primary. 

In  syphilis  there  are  very  frequently  yel- 
lowish-white, irregularly  shaped  plaques  on 
the  intima  of  the  ascending  aorta.  These 
are  slightly  raised  above  the  surface.  A  ten- 
dency to  aneurysm  formation  is  present  and 
the  aorta  is  always  more  or  less  dilated  and 
has  not  its  customary  elasticity.  Some 
have  described  a  special  form  of  mesaortitis 
due  to  syphilis,  but  the  majority  of  patholo- 
gists believe  that  this  is  not  possible.  How- 
ever, this  question  is  not  definitely  settled, 
as  small  gummata  have  been  found  beneath 
the  intima  and  the  puckered  appearance  of 
the  internal  coat,  that  is  sometimes  seen,  is 
suggestive  of  a  syphilitic  scar.  Quite  recent- 
ly, Spirochetae  pallidae  have  been  found  in 
the  thickened  intima  of  a  patient  who  died 
from  occlusion  of  the  coronary  artery.  There 
was  no  definite  history  of  syphilis  but  post- 
mortem a  scar  was  found  on  the  prepuce. 

In  the  nodular  form  of  arteriosclerosis 
there  are  places  on  the  aorta  and  its  branches 
where,  as  a  result  of  disease  and  consequent 


26  Arteriosclerosis 

stretching  of  the  media,  there  follows  a  cir- 
cumscribed dilatation  of  the  vessel.  This 
leads  to  local  compensatory  connective  tis- 
sue growth.  The  two  forms,  nodular  and 
diffuse,  are  more  often  found  together. 

The  pathological  changes  vary  much  in 
their  extent  when  portions  of  the  same  vessel 
or  of  different  vessels  are  compared.  Fre- 
quently, no  change  is  visible  from  the  out- 
side, but  again  it  is  readily  seen  that  at  one 
or  more  spots  the  artery  is  widened  or  shows 
an  irregular  contour.  On  cross  section  no 
change  in  the  lumen  may  be  foimd,  or  it  may 
show  here  and  there  places  where  it  is  widened. 
As  a  rule  the  diameter  of  the  lumen  becomes 
greater,  and  increases  as  the  disease  progresses. 
The  stretching  of  the  vessel  wall  is  of  a  pro- 
gressive character,  and  some  have  thought 
that  the  changes  in  the  wall  itself  are  in  part 
due  to  the  destruction  of  the  vasa  vasorum. 

The  changes  in  the  nodular  variety  affect 
for  the  most  part  the  aorta  and  primarily 
the  ascending  portion  of  the  arch.  Here 
there  are  yellowish  or  yellowish-white  flat 
projections  which  are  found  more  frequently 


Pathology  27 

around  the  orifices  of  the  branches,  the  orifices 
of  the  coronary  arteries  being  especially  apt 
to  be  the  seat  of  sclerosis. 

When  these  spots  represent  the  beginning 
of  true  arteriosclerosis  there  is  already  a  lesion 
in  the  media  and  compensatory  changes  are 
going  on,  the  purpose  of  which  is  to  strengthen 
the  vessel  wall.  As  the  process  advances  in 
the  arteries  these  areas  undergo  molecular 
changes  due  probably  to  destructon  of  the 
vasa  vasorum.  A  granular  debris  composed 
of  fatty  cells,  degenerated  cells  and  choles- 
terin  crystals  forms  the  so-called  atheroma- 
tous abscess.  Should  the  contents  be  dis- 
charged into  the  lumen  of  the  vessel  the 
atheromatous  ulcer  results.  Beneath  this 
the  ingrowth  of  connective  tissue  from  the 
media  and  adventitia  is  an  attempt  to  mend 
the  weak  spot.  Should  there  be  no  strength- 
ening at  such  a  point,  there  is  great  danger 
of  aneurysmal  dilatation. 

Sclerosis  of  the  radials  of  such  an  extent 
that  these  arteries  are  easily  palpable,  is  a 
different  disease  from  that  of  the  sclerosis  in 
the  aorta.  The  difference  may  be  due  pos- 
sibly to  two  factors,  (i)  the  structural   dif- 


28  Arteriosclerosis 

ference  in  the  two  vessels,  and  (2)  the  differ- 
ence in  the  sudden  strain  put  on  each  at  every 
cardiac  systole.  In  the  radial  artery  it  is 
usually  the  media  that  is  diseased,  the  origin 
of  the  lesion  is  in  the  muscle  cells,  and  the 
middle  coat  alone  is  damaged.  The  intima 
and  adventitia  are  not  essentially  involved, 
but  there  is  frequently  thickening  of  the 
intima  over  the  diseased  media.  In  the  wall 
of  the  vessel  the  changes  that  occur  are  fatty 
degeneration  of  the  muscle  cells  and  later  of 
the  elastic  fibres,  with  subsequent  deposits 
of  lime  salts  in  the  diseased  tissue .  There  may 
be  calcification  of  the  intima  alone,  but  there 
is  rarely  a  deposit  of  lime  salts  in  the  media 
without  concomitant  deposits  in  the  intima. 
This  gives  the  beaded  character  to  the  vessel. 
The  vessel  is  perceptibly  thinned  at  the  sites 
of  these  areas  and  there  result  many  small 
pouchings,  the  intima  over  these  areas  being 
much  thickened.  These  are  in  reality  true 
minute  aneurysms,  and  when  such  an  artery 
is  held  against  the  light  it  is  seen  to  be  trans- 
parent. 

On  the  contrary,  the  nodular  aorta  found 
at  autopsy  is  the  result  of  injuries  to  the  in- 


FIG.  V. 


Fig.  V.  Cross  section  of  a  coronary  artery,  x50 
showing  nodular  sclerosis.  Note  the  heaping  up  of  cells 
in  the  intima,  the  fracture  of  the  elastica,  and  the  destruc- 
tion of  the  media  beneath  the  nodule.  The  primary 
lesion  apparently  was  in  the  media.  The  thickened  intima 
is  the  effort  on  the  part  of  nature  to  heal  the  breach. 
At  such  places  as  shown  here  aneurysms  may  form. 


Pathology  29 

tima.  The  intimal  thickenings  may  be  en- 
tirely proUferative  and  represent  chronic  in- 
flammatory production  of  new  tissue. 
Changes  in  the  media  do  not  necessarily  ac- 
company such  a  lesion.  There  are  some, 
however,  who  do  not  believe  that  in  the  aorta 
the  primary  lesion  is  in  the  intima. 

The  thickening  of  the  media  in  the  small 
arteries  which  is  due  to  the  proliferation  of 
connective  tissue  beneath  the  endothelium, 
or  to  the  proliferation  of  the  endothelial  cells 
themselves,  may  cause  such  narrowing  that 
thrombosis  is  favored  and  a  distortion  of  the 
vessel  is  apt  to  occur.  However,  the  over- 
growth alone  seldom  if  ever  is  sufficient  to 
close  the  lumen  of  a  vessel.  The  total  occlu- 
sion is  brought  about  by  a  slowing  of  the 
blood  current,  and  thrombosis  which  later 
becomes  organized.  Such  places  may  be- 
come channeled  and  allow  a  certain  amount 
of  blood  to  pass  along  the  thrombosed  vessel. 
These  conditions  are  known,  the  one  as  end- 
arteritis deformans,  the  other  as  endarteritis 
obliterans. 

Now,  the  lesions  of  experimental  arterio- 
sclerosis produced  by  various  substances  in- 


30  Arteriosclerosis 

jected  into  the  circulation  of  animals,  have 
enabled  us  in  a  way  to  judge  of  the  early 
lesions  of  arteriosclerosis  in  the  human  arte- 
ries. Following  the  injection  of  small  and 
repeated  doses  of  adrenalin  over  a  certain 
interval  of  time,  changes  occur  in  the  arteries 
of  rabbits  that  are  arteriosclerotic  in  type, 
the  essential  lesion  being  a  degeneration  of 
the  muscular  and  elastic  tissue  of  the  media, 
with  the  consequent  production  of  aneiuysms 
in  the  vessel.  This  is  analogous  to  the  arte- 
riosclerosis of  the  radial  artery  in  man.  The 
degenerations  in  the  arteries  after  experimen- 
tal lesions  are  of  the  nature  of  fatty  meta- 
morphosis, and  later  proceed  to  calcification. 
Adrenalin,  barium  chloride,  digitalin,  phy- 
sostigmin,  nicotine,  and  other  substances 
have  been  found  to  exert  a  selective  toxic 
action  on  the  muscle  cells  of  the  middle  coat 
of  the  aorta.*  The  most  frequent  site  of  dis- 
ease in  these  experimental  lesions  is  the  thor- 


*  The  infundibular  portion  of  the  pituitary  body,  the 
portion  which  is  developed  from  the  infundibulum  of  the 
brain,  posseses  an  internal  secretion  which,  injected 
intravenously,  causes  a  marked  rise  of  blood  pressure  and 
slowing  of  the  heart  beat.  So  far  as  I  know  this  active 
principle  of  the  gland  has  not  been  used  to  produce  experi- 
mentally the  lesions  of  arteriosclerosis. 


Pathology  31 

acic  aorta,  and  it  is  there  that  the  most 
severe  changes  are  seen.  While  the  toxic 
action  is  felt  in  the  vessels  all  over  the  body, 
the  lesions  are  as  a  rule  scattered  and  small. 
The  thoracic  aorta  stands  the  brunt  of  the 
high  pressure,  and  this  combined  with  the 
toxic  action  of  the  drug  or  drugs,  results 
in  the  formation  of  a  fusiform  aneurysmal 
dilatation  which  stops  at  the  diaphragmatic 
opening.  The  aortic  opening  in  the  diaphragm 
seems  to  act  as  a  flood  gate,  allowing  only  a 
certain  amount  of  blood  to  flow  through, 
and  thus  the  abdominal  aorta  is  protected 
to  a  great  extent  from  the  deleterious  effects 
of  increased  pressure.  Focal  degenerative 
lesions  are,  however,  found  in  the  abdom- 
inal aorta. 

Changes  somewhat  analogous  to  those 
found  in  the  human  aorta  as  the  result  of  in- 
timal  proliferations,  are  produced  in  animals 
by  the  toxins  of  the  typhoid  bacillus  and 
streptococcus.  The  changes  caused  by  these 
toxins  are  proliferations  of  cells  in  the  intima 
and  subintimal  tissues,  and  a  breaking  up  of 
the  internal  elastic  lamina  into  several  parallel 
layers  that  stretch  themselves  between   the 


32  Arteriosclerosis 

proliferating  cells.  The  diphtheria  toxin  on 
the  contrary  produces  a  lesion  more  like  that 
produced  by  adrenalin.  All  pathologists  are 
not  agreed  as  to  whether  these  experimental 
lesions  are  truly  arteriosclerotic  or  not;  the 
general  trend  of  opinion  seems  to  be  that  suf- 
ficient work  thus  far  has  been  done  to  afford 
strong  support  to  Thoma's  views. 

The  changes  in  the  intima  constitute  the 
effort  on  the  part  of  nature  to  repair  a  defect 
in  the  vessel  wall  which  is  to  compensate  for 
the  weakened  media  and  the  widened  lumen. 
This  applies  only  to  the  diffuse  type,  not  to 
the  condition  analogous  to  that  produced  by 
the  toxin  of  the  typhoid  bacillus,  for  example. 

When  an  artery  loses  its  elasticity  and  be- 
gins to  have  connective  tissue  deposited  in 
its  walls,  the  pressure  of  the  blood  stretches 
the  vessel  now  no  longer  capable  of  retract- 
ing when  the  pulse  wave  has  passed,  and  in 
consequence  the  artery  is  actually  lengthened. 
This  necessarily  causes  a  tortuosity  of  the  ves- 
sel which  can  be  easily  seen  in  the  tempo- 
rals, brachials,  radials,  and  other  arteries  just 
beneath  the  skin. 


Pathology  33 

The  exact  mechanism  of  increase  in  blood 
pressure  is  not  satisfactorily  explained.  With 
the  exception  of  the  vessels  in  the  brain  and 
lungs,  the  smaller  arteries  are  supplied  with 
vasoconstrictor  and  vasodilator  nerve  fibres 
from  the  sympathetic  nervous  system.-  Nor- 
mally when  an  organ  is  actively  functioning 
the  vessels  are  widely  dilated  and  the  flow 
of  blood  is  rapid.  Psychic  influences  of  vari- 
ous kinds  have  a  marked  effect  on  vasomotor 
control  of  parts  of  the  body. 

It  is  conceivable  that  in  one  section  of  the 
body  the  vessels  may  be  markedly  contracted ; 
but  if  there  is  dilatation  in  some  other  part 
there  will  be  no  increased  work  on  the  part 
of  the  heart,  and  there  need  be  no  rise  of 
blood  pressure.  The  vascular  system,  while 
likened  to  a  system  of  rubber  tubes,  must  be 
thought  of  as  a  very  live  system,  every  sub- 
system having  the  property  of  separate  con- 
trol. 

For  blood  tension  to  be  raised  all  over  the 
body  there  must  be  one  of  two  causes  ;either 
the  blood  must  be  more  viscous,  or  the  con- 
ditions over  the  body  must  favor  the  general- 
ized contraction  of  a  large  capillary  area.  The 


34         -  Arteriosclerosis 

usual  cause  of  such  a  condition  is  the  pres- 
ence in  the  blood  of  some  poisonous  substance. 

It  must  be  borne  in  mind  that  the  great 
splanchnic  area  is  capable  of  holding  all  the 
blood  in  the  body,  and  in  respect  of  its  liablity 
to  arteriosclerosis,  it  is  second  only  to  the  aorta 
and  coronary  arteries.  The  enormous  area  of 
the  skin  vessels  could  probably  contain  most 
of  the  blood.  The  fact  that  the  blood  is  dis- 
tributed over  the  body  depends  on  the  tone  of 
the  vasoconstrictor  centre.  The  fact  that 
the  vessels  in  the  splanchnic  area  are  frequently 
attacked  by  sclerotic  changes  means  as  a  rule 
increase  of  work  for  the  heart.  The  resist- 
ance offered  to  the  passage  of  the  blood  means 
that  for  the  blood  to  travel  at  the  same  rate 
that  it  did  before  the  resistance  set  in,  more 
power  must  be  expended  in  its  propulsion. 
In  other  words,  the  heart  must  gradually  be- 
come accustomed  to  the  changed  conditions 
and  as  a  result  of  increased  work  the  muscle 
hypertrophies. 

In  diffuse  arteriosclerosis  the  heart  is  always 
hypertrophied.  This  is  a  result,  not  a  cause 
of  the  condition.  In  the  pure  type,  there  is 
hypertrophy  only  of  the  left  ventricle  with- 


FIG.  VI. 


Fig.  VI.  Cross  section  of  a  small  artery  in  the  mesen- 
tery. Note  that  vessel  appears  capable  of  being  much 
widened.  The  internal  elastic  lamina  is  thrown  into  folds 
somewhat  resembling  the  convolutions  of  the  brain.  Note 
also  that  the  middle  coat  of  the  artery  is  composed  almost 
entirely  of  muscle.  The  enormous  numbers  of  such  ves- 
sels in  the  mesentery  and  intestines  explains  the  ability 
of  the  splanchnic  area  to  accomodate  the  greater  part  of 
the  blood  in  the  body.  Universal  constriction  of  these 
vessels  would  naturally  render  the  intestines  anemic.  The 
vasomotor  control  of  these  vessels  plays  an  important 
role  in  the  distribution  of  the  blood.  Small  arteries  in 
the  skin  and  in  other  organs,  except  the  brain  and  lungs, 
have  a  similar  function.     Highly  magnified. 


Pathology  35 

out  dilatation  of  the  chamber.  The  muscle 
fibres  are  increased  in  number  and  size,  and 
there  are  frequently  areas  of  fibrous  myocar- 
ditis due  to  necrosis  caused  by  insufficient 
nutrition  of  the  muscle.  In  these  cases  the 
coronary  arteries  share  in  the  generalized 
arteriosclerotic  process.  The  openings  of  the 
arteries  behind  the  semilunar  valves  may 
be  very  small.  There  is  often  thickening 
and  puckering  of  the  aortic  valves  and  of  the 
anterior  leaflet  of  the  mitral  valves  leading 
at  times  to  actual  insufficiency  of  these  ori- 
fices. Later  when  the  heart  begins  to  wea- 
ken there  is  dilatation  of  the  chambers  and 
loud  murmurs  result,  caused  by  the  inabil- 
ity of  the  nondistensible  valves  to  close 
the  dilated  orifices.  Until  the  compensation 
is  established,  it  is  impossible  to  say  whether 
or  not  true  insufficiency  is  present. 

In  the  so-called  senile  type  of  arterioscle- 
rosis, a  retrogressive  change  and  not  what 
is  here  called  true  arteriosclerosis,  the  arte- 
ries may  be  so  lined  with  deposits  of  calca- 
reous matter  that  they  appear  as  pipe  stems 
or  they  may  be  tortuous.  They  feel  hard 
and    absolutely    nondistensible.     At    times, 


36  Arteriosclerosis 

no  pulse  wave  can  be  felt.  When  the  calci- 
fication is  not  so  diffuse,  the  artery  is  beaded. 
The  larger  arteries  such  as  the  brachials 
and  femorals  are  most  affected.  The  walls 
become  thinned  and  show  cracks,  and  areas 
apparently,  but  not  actually,  denuded  of  in- 
tima.  White  thrombi  may  even  be  deposi- 
ted on  these  areas  and  atheromatous  ulcers 
are  frequent  in  such  arteries.  The  danger 
of  an  embolus  plugging  one  of  the  smaller 
arteries  is  great,  and  should  the  thrombi 
be  on  the  carotid  arteries,  hemiplegia  may 
result  from  cerebral  embolism.  On  micro- 
scopical examination  of  the  arteries  there  is 
seen  extreme  degeneration  of  all  the  coats, 
the  degeneration  of  the  media  leading  almost 
to  an  obliteration  of  that  coat.  On  seeing 
arteries  such  as  these  one  wonders  how  the 
circulation  could  have  been  maintained,  and 
the  organs  nourished.  Senile  atrophy  of 
the  liver  and  kidneys  naturally  goes  hand  in 
hand  with  such  arterial  changes. 

There  is  as  a  rule  no  increase  in  arterial 
tension;  on  the  contrary  the  pressure  is  apt 
to  be  low.  This  is  readily  understood  when 
the    heart    is    seen.      This    is    small,     the 


Pathology  37 

muscle  much  thinned,  flabby  and  of  a  brown- 
ish tint,  the  so-called  "brown  atrophy".  Micro- 
scopically there  is  seen  to  be  much  fragmen- 
tation of  the  fibres  with  a  marked  increase 
in  the  brown  pigment  granules  that  surround 
the  cell  nuclei.  Cases  are  seen,  however,  in 
which  blood  pressure  increases  as  the  patient 
grows  older.  The  hearts  in  such  cases  are 
more  or  less  hypertrophied  and  show  exten- 
sive areas  of  fibroid  myocarditis. 

There  are  many  cases  of  arteriosclerosis 
that  lead  to  definite  interference  with  the 
closure  of  the  valves  of  the  heart,  particu- 
larly the  mitral  and  aortic.  It  has  been  said 
above  that  puckerings  of  the  valves  frequently 
occur.  This  arteriosclerotic  endocarditis  at 
times  leads  to  very  definite  heart  lesions, 
chiefly  mitral  insufficiency  and  aortic  insuf- 
ficiency with  murmurs  of  a  stenotic  charac- 
ter at  the  base.  There  is  rarely  true  aortic 
stenosis,  however.  The  murmur  is  caused 
by  the  passage  of  the  blood  over  the  rough- 
ened valves  and  into  the  dilated  aorta.  Aortic 
stenosis  is  one  of  the  rarest  of  the  valvular 
lesions,  and  should  be  diagnosed  only  when 
all  factors,  includng  the  typical  pulse  trac- 
ings, are  taken  into  consideration. 


38  Arteriosclerosis 

The  kidneys  as  a  nile  show  extensive  scle- 
rosis. A  very  markedly  contracted  kidney 
from  which  the  capsule  strips  with  difficulty 
may  be  present,  portions  of  the  cortex  of  the 
kidney  adhering  to  the  capsule.  This  form 
is  seen  for  the  most  part  in  chronic  nephritis, 
where  it  may  be  impossible  to  say  whether 
the  renal  or  the  heart  condition  was  primary. 
Again,  the  kidneys  may  be  increased  in  size, 
the  capsules  slightly  adherent,  the  surfaces  a 
little  rough.  Such  organs  frequently  present 
atrophic  depressed  areas,  deep  red  in  color. 
In  both  types  of  kidney  the  consistence  is 
much  increased.  On  microscopical  exami- 
nation, there  is  widespread  deposit  of  fibrous 
tissue  throughout  the  organ.  Many  of  the 
glomeruli  are  represented  only  by  empty 
spaces ;  those  which  are  seen  are  small  and  con^ 
tain  much  increased  fibrous  tissue.  The  new 
tissue  surrounds  the  tubules;  these  are  com- 
pressed and  the  tubule  cells  are  atrophied, 
and  the  arteries  show  the  changes  described 
within. 

Arteriosclerosis  of  the  pulmonary 
ARTERIES  is  an  exceedingly  rare  affection  and 
may  occur  independently  of  disease   of  the 


Pathology  39 

greater  circulation.  The  cases  in  the  Htera- 
ture  (four  in  number)  were  characterized  by 
wide-spread  thickening  of  the  pulmonary 
arteries  with  marked  hypertrophy  of  the 
right  ventricle.  In  two  of  the  cases,  no 
changes  in  the  bronchial  arteries  or  in  the 
pulmonary  veins  were  demonstrable.  Three 
of  the  cases  occurred  in  persons  younger  than 
thirty  five  years. 

SCI.EROSIS     OP     THE      VEINS — ^PHI^EBOSCLE- 

ROSiS — not  infrequently  occurs  with  arterio- 
sclerosis. It  is  seen  in  those  cases  character- 
ized by  increased  blood  pressure.  Such  in- 
creased pressure  in  the  veins  is  due  for  ex- 
ample to  cirrhosis  of  the  liver  which  affects 
the  portal  circulation,  or  to  mitral  stenosis 
which  affects  the  pulmonary  veins.  The  af- 
fected vessels  are  usually  dilated.  The  in- 
tima  shows  compensatory  thickening  espe- 
cially where  the  media  is  thinned.  Occa- 
sionally hyaline  degeneration  or  calcification 
of  the  new-formed  tissue  is  seen.  "Without 
existing  arteriosclerosis  the  peripheral  veins 
may  be  sclerotic,  usually  in  conditions  of  de- 
bility, but  not  infrequently  in  young  persons" 
(Osier). 


40  Arteriosclerosis 

In  many  cases  of  arteriosclerosis,  the  patho- 
logical changes  are  not  confined  to  the  arte- 
ries but  are  found  in  the  veins  as  well  as  in 
the  capillaries.  Such  cases  could  be  called 
angiosclerosis. 


CHAPTER  IV. 

ETIOLOGY. 

The  causes  of  arteriosclerosis  are  many  and 
varied.  No  two  of  us  have  the  same  resist- 
ing power  towards  poisons  that  circulate  in 
the  blood.  Some  go  through  life  exposed  to 
all  the  infectious  diseases  without  ever  be- 
coming infected,  while  others  fall  easy 
victims  to  every  disease  that  comes  no 
matter  how  careful  they  may  be,  and  it 
is  quite  the  same  in  regard  to  the  re- 
sistance of  the  arterial  tissues.  If  the  tubing 
is  of  first  class  quality  and  the  individual  does 
not  place  too  much  strain  on  it,  he  may  live 
to  the  Biblical  three-score  years  and  ten,  and 
possess  arteries  that  have  undergone  such 
slight  changes  that  they  are  not  palpable. 
Such  a  person  is,  however,  the  exception.  On 
the  other  hand  if  the  tissue  is  of  poor  quality, 
even  the  ordinary  wear  and  tear  of  living 
causes  early  changes  in  the  vessels,  and  a  per- 
son of  forty  may  have  hard  arteries. 

We  have  described  in  the  previous  chapter 
the  changes  which  normally  occur  in  the  arte- 


43  Arteriosclerosis 

ries  as  age  advances.  An  artery  that  is  nor- 
mal for  a  man  of  fifty  years  would  be  distinctly 
abnormal  for  a  boy  of  fifteen. 

Two  broad  divisions  of  arteriosclerosis  may 
be  made:  (i)  Congenital,  or  the  result  of 
inherited  tendency ;  (2)  Acquired.  Of  these, 
the  acquired  group  is  by  far  the  larger  and 
more  important. 

CoNGENiTAiv  FORM — ^When  Dr.  O.  W.  Holmes 
was  asked  how  to  live  to  the  age  of  seventy, 
he  replied  that  a  man  should  begin  to  pick  his 
ancestors  one  hundred  years  before  he  was 
bom.  Our  parents  determine  the  character 
of  the  tissues  with  which  we  start  in  life  and 
this  determines  our  general  resistance.  We 
might  properly  speak  of  congenital  arterio- 
sclerosis where  the  affected  individual  had  poor 
arterial  tissue  with  which  to  begin  life,  for 
that,  in  a  sense,  is  a  congenital  defect,  and 
arterial  tissue  that  is  bad  is  prone  to  disease. 

Arteriosclerosis  may  occur  in  infants.  Cases 
have  been  reported  of  calcification  of  the  ar- 
teries in  infants  and  children.  The  arterio- 
sclerosis may  occur  without  nephritis  or  rise 
of  blood  pressmre.  Cerebral  hemorrhage  in 
a  child  of  two  years  has  been  seen.  Heredity 


Etiology  43 

in  these  cases  plays  a  most  important  role. 
In  many  of  the  reported  cases  there  was  no 
question  of  congenital  syphilis.  Aneurysms, 
single  or  multiple,  have  been  found  in  the 
arteries  of  children,  and  even  the  pulmonary 
artery  may  show  sclerotic  canges. 

Acquired  form — ^AU  the  cases  that  are 
usually  seen  belong  in  this  group.  The  cases 
of  the  previous  group  are  very  rare  and  clini- 
cally are  not  of  very  great  importance. 

Hypertension  holds  first  place  as  a  cause 
of  arteriosclerosis.  With  every  systole  of 
the  heart,  blood  is  forced  out  into  the  arterial 
system  against  a  certain  amount  of  resist- 
ance represented  by  the  tonicity  of  the  capil- 
lary area,  and  the  amount  of  cohesion  be- 
tween the  viscous  blood  and  the  walls  of  the 
arterioles.  When  a  dilatation  of  the  capil- 
laries over  any  large  area  takes  place,  the 
blood  pressure  falls,  providing  there  is  no 
compensatory  contraction  in  other  areas  to 
make  up  for  the  decreased  resistance  in  the 
dilated  vessels.  The  viscosity  of  the  blood, 
as  such,  probably  has  very  little  effect  on  the 
resistance  to  the  flow.  With  the  systole  of 
the  heart  there  is  a  sudden  dilatation  of  the 


44  Arteriosclerosis 

arch  of  the  aorta,  and  a  wave  of  expansion 
follows,  which  is  transmitted  to  the  periphery 
and  is  lost  only  in  the  capillaries. 

The  blood  pressure  is  constantly  changing. 
Physiologically  there  are  relatively  wide  varia- 
tions in  the  pressure  in  a  perfectly  normal 
individual.  There  are  some  persons  who 
have  hypotension,  a  blood  pressure  much 
below  the  normal.  Such  persons  have  usu- 
ally small  hearts,  small  aortas,  and  they  seem 
to  have  but  little  resistance  to  disease.  Many 
diseases,  especially  the  prolonged  fevers, 
diminish  markedly  the  blood  presstue.  Whether 
the  hypertension  is  the  cause  of  the  structural 
changes  that  are  found  in  the  walls  of  the  ves- 
sels, or  is  the  result  of  the  diminished  area  of  the 
arterial  tree  through  which  the  same  amount 
of  blood  has  to  be  driven  as  before  the  vessel 
walls  became  narrowed,  is  still  disputed.  As 
has  been  stated,  experimental  evidence  would 
tend  to  place  the  initial  blame  upon  the  poisons 
circulating  in  the  blood,  which  first  damage 
the  vessel  walls.  The  subsequent  changes 
then  produce  thickening  and  inelasticity. 
Some  think  (AUbutt)  that  the  hypertension 
is  primary.     There  are  cases   seen  clinically 


Etiology  45 

that  lend  support  to  this  view.  Not  infre- 
quently individuals  in  middle  life  begin  to 
show  increase  of  arterial  blood  pressure  with- 
out discoverable  cause.  It  is  probable,  how- 
ever, that  such  cases  are  those  of  beginning 
nephritis  where  the  urine  is  perfectly  normal, 
as  far  as  chemical  examination  reveals,  but 
the  circulation  of  some  poison  in  the  blood  cau- 
ses a  rise  of  pressure.  This  is  a  very  inter- 
esting group  of  cases,  and  more  will  be  said 
about  it  later. 

No  age  is  exempt  from  the  lesions  of  arte- 
riosclerosis if  we  consider  the  two  groups- 
However,  the  disease  is  seen  for  the  most  part 
in  persons  past  middle  life.  The  relative  fre- 
quency with  which  it  is  found  in  the  different 
decades  depends  on  so  many  factors  that  it 
is  of  no  value  to  tabulate  them.  As  has  been 
stated,  arteriosclerosis  of  all  types  is  an  in- 
volution process  that  advances  with  age. 
Longevity  is  a  question  of  the  integrity  of  the 
arterial  tissue,  and  no  one  can  tell  what  sort 
of  "vital  rubber"  (Osier)  anyone  of  us  has. 
However,  many  with  poor  tubing  may  make 
such  use  of  it  that  it  will  outlast  good  tubing 
that   is   badly   treated.     Unfortunately    we 


46  Arteriosclerosis 

have  no  way  of  telling  early  enough  with  just 
what  sort  of  arterial  tissue  we  are  starting 
life. 

Sex.  There  Is  no  doubt  that  men  are  far 
more  prone  to  arterial  disease  than  women 
are.  This  is  explained  by  the  greater  exposure 
of  men  to  those  conditions  of  life  which  tend 
to  produce  high  tension,  and  so  to  produce 
arteriosclerosis,  or  vice  versa.  Arterioscle- 
rosis in  women  is  not  often  seen  until  after 
the  fiftieth  year.  Cases  of  the  most  extreme 
grade  of  pipe  stem  arteries  are,  however,  seen 
in  old  women,  and  calcified  arteries  are  not 
hard  to  find  among  the  inmates  of  an  old 
woman's  home. 

Race.  The  most  beautiful  examples  of 
arteriosclerosis  in  this  country  are  seen  in  the 
negro.  Not  only  is  this  disease  more  frequent 
in  the  black  race,  but  the  age  of  onset  is  much 
earlier  than  in  the  Caucasian.  The  accidents 
of  arteriosclerosis,  viz.  aneurysm,  cerebral 
hemorrhage,  etc.,  are  more  common  among 
the  negro  males.  The  etiological  factors 
that  are  most  often  found  in  the  history  are 
the  prevalence  of  syphilis  and  hard  physical 
labor. 


Etiology  47 

Occupation.  Certain  occupations  have 
a  distinct  causal  relationship  to  arterioscle- 
rosis; among  such  are  particularly  those  en- 
tailing prolonged  muscular  exercise,  especially 
if  much  lifting  is  necessary.  Everyone  is 
familiar  with  the  phenomena  accompanying 
the  exertion  of  lifting.  The  breath  is  drawn 
in,  the  glottis  is  closed,  and  the  muscles  of  the 
chest  wall  are  held  rigidly  while  the  exertion 
lasts.  This  causes  a  great  increase  in  blood 
pressure,  and  constant  repetition  of  this  will 
produce  permanent  high  tension.  In  hos- 
pitals, the  stevedores  as  a  class  have  marked 
arteriosclerosis,  and,  almost  without  excep- 
tion, they  are  comparatively  young  men. 
Occupations  that  are  accompanied  with  pro- 
longed mental  strain,  such  as  now  occur  to 
the  heads  of  large  manufacturing  and  finan- 
cial institutions,  also  predispose  to  early  arte- 
rial changes.  Psychic  activity,  especially 
when  it  is  accompanied  by  worry,  is  a  potent 
factor  in  the  production  of  the  increased  blood 
pressure  which  is  the  chief  factor  in  producing 
arterial  disease.  There  are,  however,  men 
who  seem  not  to  be  harmed  by  the  constant 


48  Arteriosclerosis 

wear  and  tear  of  our  modem  life.     These  are 
the  exceptions. 

Workers  in  factories  where  paint  is  made 
and  the  ingredients  hand  mixed,  are  prone 
to  develop  arteriosclerosis  early  in  life.  It 
has  been  found  that  the  laborers  most  apt  to 
be  victims  of  lead  intoxication  are  those 
who  are  careless  in  their  habits  of  cleanliness, 
particularly  in  regard  to  the  fingernails.  The 
continuous  absorption  of  lead  into  the  system, 
brings  about  a  condition  of  hypertension  that 
has  its  inevitable  results. 

The  fact  is  that  any  occupation  which  en- 
tails either  the  absorption  of  toxic  substances, 
or  prolonged  muscular  labor,  will  hasten 
markedly  the  onset  of  arterial  disease. 

Infectious  diseases.  As  more  study 
has  been  given  to  the  arteries  in  persons  who 
have  died  of  the  acute  infectious  diseases, 
more  has  come  to  light  concerning  the  effects 
of  the  toxins  of  these  diseases  on  the  vessel 
walls.  In  the  arteries  of  children  who  have 
died  of  measles,  scarlet  fever,  diphtheria,  cere- 
brospinal meningitis,  etc. ,  degenerative  changes 
in  the  arteries  occur,  modified  only  by  the 
length  of  time  that  the  toxins  have  acted. 


Etiology  49 

Thayer  has  shown  that  the  arteries  of  those 
who  have  passed  through  an  attack  of  moder- 
ately severe  or  severe  typhoid  fever  are  as  a 
rule  more  readily  palpable  than  are  the  ves- 
sels of  persons  of  corresponding  years  who 
have  never  had  the  disease.  Clinically  the 
typhoid  toxin  appears  to  cause  the  early  pro- 
duction of  arteriosclerosis.  The  changes  in 
the  arteries  occur  for  the  most  part,  and  always 
earlier,  in  the  peripheral  arteries,  and  the 
media  is  chiefly  affected.  Minute  yellowish 
patches  are  foimd  on  the  aorta,  carotids,  and 
coronaries .  In  persons  who  have  passed  through 
an  attack  of  one  of  the  fevers,  and  have  later 
died  from  some  other  cause,  regenerative  chan- 
ges are  sometimes  found  to  have  taken  place 
in  the  arteries,  consisting  of  an  ingrowth  of 
elastic  fibres  from  the  intact  adventitia  to 
the  diseased  media. 

Syphilis.  This  is  one  of  the  most  import- 
ant of  the  etiological  factors  in  the  produc- 
tion of  arteriosclerosis.  Acute  aortitis  af- 
fecting the  ascending  and  transverse  portions 
of  the  arch  of  the  aorta  is  very  commonly 
seen,  and  the  irregular,  scattered,  slightly 
raised,   yellowish- white  patches  of  sclerosis  in 


50  Arteriosclerosis 

the  arch  which  are  found  years  after  the  syphi- 
litic lesion,  are  considered  by  some  to  be  very 
characteristic  of  syphilis.  A  mesaortitis 
also  occurs  that  is  frequently  a  locus  minoris 
resistentiae  where  an  aneurysm  forms.  In 
fact,  it  is  claimed  (Osier)  that  all  aneurysms 
occurring  in  persons  under  thirty  years  of 
age  are  due  to  syphilitic  aortitis.  In  the  late 
stages  of  syphilis  the  arterial  lesions  may  be 
of  a  diffuse  character. 

Chronic  drug  intoxications.  Lead,  to- 
bacco, and  according  to  some,  tea  and  coffee, 
are  to  be  classed  as  causal  factors  in  the  pro- 
duction of  arteriosclerosis.  Certain  it  is  that 
all  these  substances  have  a  tendency  to  raise 
the  arterial  pressure,  but  whether  the  drug 
itself  causes  first  a  degeneration,  and  later 
hypertension  results,  or  vice  versa,  is 
not  yet  positively  known.  We  have  just 
mentioned  that  lead  particularly  has  a  marked 
effect  in  producing  arterial  lesions.  Other 
drugs  as  adrenalici,  barium  chloride,  physo- 
stigmin,  etc.,  while  producing  experimental 
arteriosclerosis,  hardly  could  produce  the 
disease  in  man.  Alcohol  has  been  blamed 
or  much,  and  as  an  etiological  factor  in  the 


Etiology  51 

production  of  arteriosclerosis  formerly  was 
accorded  a  first  place.  More  recently  much 
doubt  has  been  thrown  on  this  supposition  by 
the  work  of  Cabot,  who  showed  that  the  mere 
drinking  of  even  large  quantities  of  spirits 
had  no  effect  in  producing  arterial  disease. 
Nevertheless  it  is  maintained  by  most  cli- 
nicians that  alcohol  is  one  of  the  most  com- 
mon causes  of  arterial  disease,  and  with 
this  opinion  we  agree.  Just  what  role  tobacco 
plays  is  difficult  to  say.  My  own  opinion  is,  that 
of  itself  when  used  in  moderation,  it  has  no 
ill  effects.  However  as  tobacco  is  a  drug 
that  raises  markedly  the  blood  pressure,  ex- 
cessive use  must  be  held  responsible  for  the 
production  of  arteriosclerosis.  It  is  difficult 
to  separate  its  effects  from  those  produced 
by  eating  and  drinking. 

OvER-EATiNG.  There  can  be  no  doubt 
but  that  the  constant  overloading  of  the  stom- 
ach with  rich  or  difficultly  digestible  food,  is 
responsible  for  a  large  number  of  cases  of  ar- 
teriosclerosis. Everyone  must  have  noted 
the  increase  in  force  and  volume  of  the  heart 
beat  after  the  ingestion  of  a  large  meal.  The 
constant   repetition   of   such  processes  con- 


52  Arteriosclerosis 

ceivably  can  lead  to  damage  to  the  vessel 
walls  through  hypertension.  In  how  far  the 
toxins  absorbed  from  the  intestinal  tract  are 
responsible  for  the  arterial  disease,  it  is  not 
possible  to  say.  However,  they  probably  do 
play  a  certain  etiological  role,  it  may  be  the 
whole  role. 

]\IentaIv  strain.  Worry  kills  more  people 
than  work.  The  high  pressure  under  which 
so  many  of  our  people  now  work  is  respon- 
sible for  a  not  inconsiderable  number  of  cases 
of  arteriosclerosis.  The  activities  of  the  mod- 
em life  with  its  multitude  of  cares  and  worries 
bring  many  a  young  head  to  the  grave. 

Muscular  overwork.  This  is  to  be  rec- 
koned with  as  an  etiological  factor.  One 
sees  it  especially  among  the  laboring  class  in 
both  whites  and  negroes.  Possibly  other 
factors  as  alcohol  and  coarse  heavy  food  con- 
tribute to  the  early  arterial  degeneration. 
Hypertrophy  of  the  heart  occurs  in  athletes, 
and  statistics  gathered  among  the  oarsmen 
especially,  show  a  relatively  high  mortality 
at  the  different  decades  traceable  to  the  high 
tension    produced    while    in    training.     This 


Etiology  53 

question  deserves  more  consideration    than 
has  been  accorded  it. 

RENaIv  disease.  Chronic  disease  of  the 
kidneys  is  one  of  the  surest  producers  of  in- 
creased tension;  in  fact,  some  see  in  high 
tension,  even  without  demonstrable  kidney 
lesions,  the  earliest  sign  of  a  chronic  progres- 
sive nephritis.  There  are  many,  however, 
who  hold  that  there  may  be  exceedingly  high 
blood  pressures  without  kidney  disease.  It 
is  possible  to  divide  the  cases  into  two  groups 
that  we  may  call,  (i)  primary,  (2)  secondary. 
By  the  primary  renal  disease  is  meant  the 
group  of  cases  where  the  kidney  disease  un- 
doubtedly antedates,  by  a  shorter  or  longer 
time,  the  development  of  the  arteriosclerosis ; 
in  other  words  the  arterial  disease  appears  to 
be  caused  by  the  kidney  disease. 

By  the  secondary  renal  disease  is  meant 
the  group  of  cases,  possibly  a  small  group, 
where  the  arterial  disease  leads  to  the  forma- 
tion of  the  kidney  lesions.  Where  the  first 
group  occurs  for  the  most  part  in  compara- 
tively young  persons,  the  second  group  is  the 
result  of  involuntionary  processes  due  to  ad- 
vanced age. 


54  .  Arteriosclerosis 

We  have  learned  that  however  careful  ana- 
lysis of  the  urine  may  be,  we  can  not  be  sure 
of  the  pathological  state  of  the  kidney  which 
secretes  the  urine.  Too  often  so-called  nor- 
mal urine  will  be  secreted  by  a  badly  diseased 
kidney,  whereas  a  urine  which  contains  con- 
siderable albumen  and  many  casts  may  be 
secreted  b}''  a  kidney  almost  perfectly 
healthy,  the  lesions  being  only  of  a  transient 
and  trivial  nature. 

Too  much  must  not  be  expected  of  any  one 
special  method  of  examination;  the  whole 
individual  must  be  viewed  from  every  stand- 
point. 


CHAPTER  V. 

SYMPTOMS  AND  PHYSICAI.  SIGNS. 

Gknerai^ — As  involution  processes  are 
physiological,  as  has  been  described  (vide  in- 
fra) ,  arteriosclerosis  may  assume  an  advanced 
grade  and  run  its  course  devoid  of  symptoms 
referable  to  diseased  arteries.  It  is  doubt- 
ful if  the  sclerosis  itself  could  produce  symp- 
toms, except  in  cases  later  to  be  described, 
were  it  not  that  the  organs  supplied  by  the 
diseased  arteries  suffer  from  an  insufficient 
blood  supply  and  the  symptoms  then  become 
a  part  of  the  symptom  complex  of  any  or  all 
the  affected  organs. 

There  are  cases,  however,  in  comparatively 
young  persons  where  a  combination  of  cer- 
tain ill-defined  symptoms  gives  a  clue  to  the 
underlying  pathological  processes.  These 
symptoms  of  early  arteriosclerosis  are  the 
result  of  slight  and  variable  disturbances  in 
the  circulation  of  the  various  organs.  Nor- 
mally there  are  frequent  changes  in  the  blood 
pressure  in  the  organs  but  the  vasomotor 
control  of  normal  elastic  vessels  is  so  perfect 


56  Arteriosclerosis 

that  no  symptoms  are  noted  by  the  individual. 
When  the  arteries  are  sclerosed,  they  are 
less  elastic  and  the  blood  supply  is,  therefore, 
less  easily  regulated.  At  times  symptoms 
occur  only  after  effort.  The  patient  may 
tire  more  readily  than  he  should  for  a  given 
amount  of  mental  or  bodily  exercise;  he  is 
weary  and  depressed,  and  occasionally  there 
is  noted  an  unusual  intolerance  of  alcohol  or 
tobacco.  Vertigo  is  common  especially  on 
rising  in  the  morning  or  in  suddenly  chang- 
ing from  a  sitting  to  a  standing  position. 
There  may  be  dull  headache  that  the  accu- 
rate fitting  of  glasses  does  not  alleviate.  Un- 
usual irritability  or  somnolency  with  a  disin- 
clination to  commence  a  new  task  may  be 
present.  Sometimes  the  effort  of  concen- 
trating the  attention  is  sufficient  to  increase 
the  headache.  This  has  been  called  "the 
sign  of  the  painful  thought".  Numbness 
and  tingling  in  the  hands,  feet,  arms,  or  legs 
are  also  complained  of,  and  neuralgias,  not 
following  the  course  of  the  nerves  but  of  the 
arteries,  also  occur.  It  is  important  to  re- 
member that  the  train  of  symptoms  resemb- 
ling neurasthenia  in  a  person  over  forty-five 


Symptoms  and  Physical  Signs  57 

years  old  may  be  incipient  arteriosclerosis. 
This  tardy  neurasthenia  frequently  accom- 
panies cancer,  tuberculosis,  diabetes  and  in- 
cipient general  paralysis,  as  well  as  incipient 
arteriosclerosis. 

Bleeding  from  the  nose,  epistaxis,  taking 
place  frequently  in  a  middle-aged  person, 
sometimes  is  an  early  symptom.  The  bleed- 
ing may  be  profuse  but  is  rarely  so  large  as 
to  be  positively  harmful.  In  fact,  it  may 
do  much  good  in  relieving  tension.  Slight 
oedema  of  the  ankles  and  legs  is  seen.  Dysp- 
noea on  slight  exertion  is  not  uncommon. 
Dyspeptic  symptoms  are  not  infrequent, 
pyrosis  (heartburn) ,  a  feeling  of  fulness  after 
meals  with  belching  or  a  feeling  of  weight  in 
the  epigastrium.  The  dyspeptic  symptoms 
may  be  so  marked  that  one  might  almost 
speak  of  a  variety  of  arteriosclerosis,  the  dys- 
peptic type.  For  quite  a  while  before  any 
symptoms  that  woulddefinitely  fixthecaseas 
one  of  undoubted  arteriosclerosis,  the  patient 
complains  that  foods  which  previously  were 
digested  with  no  difficulty  now  give  him  gastric 
distress.  The  examination  of  the  stomach 
contents  of  a  patient  presenting  gastric  symp- 


58  Arteriosclerosis 

toms  reveals  usually  a  subacidity.  The  total 
acidity  measured  after  the  Ewald  test  meal 
may  be  only  20  and  the  free  HCl  may  be  ab- 
sent. Attention  has  been  called  to  an  un- 
natural pallor  of  the  face  in  early  arterio- 
sclerosis. Progressive  emaciation  is  some- 
times seen  in  cases  of  arteriosclerosis  and 
may  be  the  only  symptom  of  which  the  pa- 
tient complains. 

Hypertension — Not  all  cases  of  arterio- 
sclerosis are  accompanied  by  increased  arte- 
rial tension.  As  has  been  stated  in  a  previ- 
ous chapter,  the  blood  pressure  in  the  arte- 
rial system  depends  chiefly  on  two  factors, 
viz.;  the  degree  of  peripheral  (capillary)  re- 
sistance and  the  force  of  the  ventricular  con- 
traction. The  highest  arterial  pressures  re- 
corded with  the  sphygmomanometer  occur 
not  in  pure  arteriosclerosis  but  in  cases  where 
there  is  concomitant  chronic  interstitial  dis- 
ease of  the  kidneys.  When  this  is  found 
there  is  always  arteriosclerosis  more  or  less 
marked.  In  cases  where  the  arteries  are  so 
sclerosed  that  they  feel  like  pipe  stems  there 
may  be  an  actual  decrease  in  the  blood  pres- 
sure.    Hence  the  clinical  measuring  of  the 


FiG.  VII. 


Fig.  VII.  Enormous  hypertrophy  of  left  ventricle  due 
to  prolonged  increased  peripheral  resistance.  Note  that 
the  whole  anterior  surface  of  the  heart  is  occupied  by  the 
left  ventricle.  The  right  ventricle  does  not  appear  to  be 
much  affected.  A  case  of  chronic  nephritis.  One-half 
normal  size. 


Symptoms  and  Physical  Signs  59 

pressure  in  the  brachial  artery  alone  is  not 
sufficient  for  a  diagnosis  of  arteriosclerosis. 
A  persistent  high  blood  pressure  even  with 
normal  urinary  findings  is  not  a  sign  of  arte- 
riosclerosis but  of  incipient  chronic  nephritis. 
The  high  tension  later  will  lead  to  the  pro- 
duction of  sclerosis  of  the  arteries  but  in  these 
cases  the  kidney  is  primarily  at  fault. 

The  heart — When  the  arterial  tree  be- 
comes narrowed  and  the  resistance  offered 
to  the  flow  of  blood  thereby  is  increased, 
more  muscular  work  is  required  of  the  left 
ventricle  and  according  to  the  general  laws 
which  govern  muscles  the  ventricle  hypertro- 
phies. There  is  an  actual  increase  in  num- 
ber of  fibres  as  well  as  an  increase  in  the  size 
of  the  individual  fibres.  Some  of  the  best 
examples  of  simple  hypertrophy  of  the  left 
ventricle  are  found  under  such  circumstances. 
The  chambers  as  a  rule  do  not  dilate  until 
the  resistance  becomes  greater  than  the  con- 
traction can  overcome,  when  symptoms  of 
broken  compensation  of  the  heart  take  place. 
The  hypertrophy  of  the  left  ventricle  brings 
more  of  this  portion  of  the  heart  towards 
the  anterior  chest  wall.     The  enlargement 


60  Arteriosclerosis 

is  towards  the  left  also,  consequently  the 
apex  beat  is  found  below  and  to  the  left  of 
its  usual  site,  even  an  inch  or  more  beyond 
the  nipple  line.  The  impulse  is  heaving, 
pushing  the  palpating  hand  forcibly  up  from 
the  chest  wall.  The  visible  area  of  pulsa- 
tion may  occupy  three  interspaces  and  the 
precordium  is  seen  to  heave  with  every  sys- 
tole. On  auscultation  the  second  sound  at 
the  aortic  cartilage  is  ringing,  clear,  and  ac- 
centuated. Not  infrequently,  too,  the  first 
sound  is  loud  and  booming  but  has  a  curious 
muffled  sound  that  may  even  be  of  a  mur- 
murish  quality.  The  leaflets  of  the  mitral 
valve  may  be  the  seat  of  sclerosis,  the  edges 
slightly  thickened  and  not  quite  approxi- 
mating causing  a  definite  murmur  with  every 
systole.  This  murmur  may  be  transmitted 
out  into  the  axilla  and  heard  at  the  inferior 
angle  of  the  left  scapula. 

PalpabIvE  Arteries — Not  every  artery 
that  can  be  felt  is  the  subject  of  arterioscle- 
rosis, and,  as  has  been  stated,  palpable  arte- 
ries being  more  or  less  a  condition  of  advanc- 
ing years,  judgment  as  to  whether  the  artery 
is  pathologically  or  physiologically  thickened 


Symptoms  and  Physical  Signs         61 

may  be  a  matter  of  individual  opinion.  A 
radial  artery  that  lies  close  to  the  lower  end 
of  the  radius  and  can  actually  be  seen  to 
pulsate  when  the  hand  is  held  slightly  ex- 
tended on  the  back  of  the  wrist,  is  easily  felt 
but  must  not,  therefore,  be  considered  a 
sclerosed  artery.  The  radial  may  be  so  deeply 
situated  in  the  wrist  of  a  fat  subject  that  it 
is  difficultly  palpable.  Yet  the  two  cases 
just  described  may  have  arteries  of  identical 
structure,  there  being  no  more  retrogressive 
changes  in  the  one  than  in  the  other.  "Ex- 
perience is  fallacious  and  judgment  difficult". 

There  is  also  a  right  way  and  a  wrong  way 
to  palpate  the  artery,  the  radial  for  example. 
No  accurate  data  can  ever  be  obtained  by 
feeling  the  artery  with  one  hand.  The  small, 
contracted,  wiry  artery  of  a  chronic  nephritic 
may  feel  like  a  pipe  stem,  but  if  properly  felt 
the  mistake  will  not  be  made  of  considering 
such  an  artery  an  unusually  sclerosed  one. 

To  palpate  the  radial  artery,  both  hands 
are  used.  With  the  middle  finger  of  the  right 
(left)  hand  the  artery  is  compressed  peri- 
pherally, that  is,  nearest  the  wrist.  The 
blood  is  then  pressed  out  of  the  artery  with 


62.  Arteriosclerosis 

the  middle  finger  of  the  left  (right)  hand, 
so  as  to  obliterate  completely  the  pulse  wave 
and  the  two  or  three  inches  between  the  mid- 
dle fingers  are  felt  with  the  index  fingers. 
By  holding  the  finger  firmly  on  the  artery 
near  the  wrist  so  as  to  block  any  wave  that 
may  come  through  the  palmar  arch  by  anas- 
tomosis with  the  ulnar  artery  and  by  releas- 
ing pressure  on  the  proximal  middle  finger, 
some  idea  may  be  had  of  the  degree  of  pulse 
tension.  However,  no  amount  of  practice 
can  more  than  approximate  the  tension  and 
when  one  is  surest  that  he  can  tell  how  many 
miUimeters  of  pressure  there  is,  he  is  apt  to 
be  farthest  wrong  when  he  checks  his  guess 
with  the  sphygmomanometer. 

Much  may  be  learned  from  carefully  pal- 
pating the  peripheral  arteries,  and,  as  a  rule, 
the  sclerosis  of  these  arteries  means  general 
arteriosclerosis  although  there  are  many  ex- 
ceptions to  this. 

Ocular  symptoms — ^These  are  important 
but  are  as  a  rule  not  found  because  not  looked 
for.  Not  every  practitioner  is  skilled  in  the 
use  of  the  ophthalmoscope.  Frequently, 
the  disease  is  recognized  first  by  the  ophthal- 


Symptoms  and  Physical  Signs         63 

mologist.  In  general,  the  symptoms  are 
gradual  loss  of  acute  vision,  and  attacks  of 
transient  loss  of  vision.  The  explanation 
which  has  been  offered  for  these  phenomena 
is  the  contraction  in  a  diseased  central  artery. 
In  the  fundus  are  seen  increased  tortuosity 
of  the  retinal  vessels  and  their  terminal  twigs 
with  more  or  less  bending  of  the  vessels  at 
their  crossings.  The  arteries  are  terminal 
ones  and  small  patches  of  retinitis  are  there- 
fore found.  The  changes  have  been  divided 
into  (i)   Suggestive,   (2)   Pathognomonic. 

Under  (i)  are  (a)  Uneven    calibre    of    the 
vessels, 

(b)  Undue  tortuosity, 

(c)  Increased  distinctness 
of  the  central  light  streak, 

(d)  An  unusually  light  color 
of  the  breadth  of  the  ar- 
tery. 

Under  (2)  are  (a)  Changes  in  size  and 
breadth  of  the  retinal  ar- 
teries so  that  they  look 
beaded, 
(b)  Distinct  loss^of  trans- 
lucency, 


64  Arteriosclerosis 

(c)  Alternate  contractions 
and  dilatations  in  the 
veins, 

(d)  Most  important  of  all, 
the  indentation  of  the 
veins  by  the  stiffened  ar- 
teries. 

Moreover,  there  is  the  arcus  senilis,  the 
fine  translucent  to  opaque  circle  surrounding 
the  outer  portion  of  the  iris.  Practically 
every  one  with  a  well  marked  arcus  senilis 
has  arteriosclerosis,  but  vice  versa  not  every 
one  with  even  marked  arteriosclerosis  has 
an  arcus  senilis. 

Nervous  symptoms — The  onset  of  arte- 
riosclerosis is,  in  the  majority  of  cases,  so  in- 
sidious that  certain  nervous  manifestations 
due  in  all  probability  to  disturbances  in  blood 
pressure,  are  present  long  before  the  actual 
sclerosis  of  the  arteries  can  be  felt.  These 
nervous  symptoms  are  at  times  the  sign  posts 
to  show  us  the  way  to  the  accurate  diagnosis. 
There  may  be  gradual  increase  in  irritability 
of  temper,  inability  to  sleep,  vertigo  even 
extending  to  transient  attacks  of  unconscious- 
ness.     Loss    of    memory  for    details    and 


Symptoms  and  Physical  Signs         65 

nervous  indigestion  may  be  present.  Var- 
ious paresthesias  as  numbness,  tingling,  a 
sense  of  coldness  or  of  heat  or  burning,  a 
sense  of  stiffness  or  even  actual  stiffness  or 
weakness  may  occur  in  the  arms  and  legs, 
more  frequently  in  the  legs.  The  pain  com- 
plained of  may  be  due  to  occlusion  of  an  ar- 
tery, although  evidence  for  this  is  lacking. 
It  has  been  thought  by  some  that  the  pain 
in  angina  pectoris  might  be  due  to  this  cause. 

Several  curious  and  interesting  diseases 
which  have  been  thought  by  some  to  have 
arteriosclerosis  as  a  basis  are  accompanied 
by  pain.  Such  are  erythromelalgia,  Ray- 
naud's disease,  "dead  fingers",  and  inter- 
mittent claudication. 

There  is  a  group  of  cases  that  is  character- 
ized by  a  period  of  prolonged  low  fever,  the 
fever  never  rising  as  a  rule  above  100.5  de- 
grees F.  to  1 01  degrees  F.,  but  lasting  for 
weeks  and  even  months.  Except  for  a  feel- 
ing of  malaise,  slight  headache,  and  possibly 
slight  dyspnoea  on  exertion,  the  patient  seems 
to  be  fairly  well.  When  after  careful  obser- 
vation and  elimination  of  all  the  common 
causes  of  prolonged  fever,  including  syphilis 


66  Arteriosclerosis 

and  tuberculosis,  one  is  at  a  loss  to  know 
what  the  disease  is,  there  may  be  a  possibil- 
ity that  subacute  arteriosclerosis  may  be  the 
cause  of  the  symptoms.  There  are  times  when 
the  disease  may  progress  very  rapidly.  Cases 
are  seen  in  which  the  peripheral  arteries  be- 
come hard  and  stiff  a  short  two  years  from 
the  onset. 

"Well  developed  arteriosclerosis  shows  foiu: 
pathognomonic  signs:  (i)  Hypertrophy  of 
the  heart,  (2)  Accentuation  of  the  aortic  sec- 
ond sound,  (3)  Palpable  thickening  of  the 
arteries,  and  (4)  Heightened  blood  pressure. 
However,  it  must  not  be  inferred  that  these 
signs  must  be  present  in  order  to  diagnose 
arteriosclerosis.  It  has  already  been  said 
that  a  very  marked  degree  of  thickening 
with  even  calcification  of  the  palpable 
arteries  may  occiu"  with  absolutely  no  in- 
crease of  blood  pressure,  and  at  autopsy  a 
small  flabby  heart  may  be  found. 

In  this  connection,  the  classification  of 
Prof.  T.  Clifford  Allbutt  is  worthy  of  extended 
notice.  He  divides  the  causes  of  arterioscle- 
rosis clinically  into  three  classes:  i.  The 
toxic  class — the  results  of  poisons    of  the 


Symptoms  and  Physical  Signs  67 

most  part  of  extrinsic  origin,  chiefly  those  of 
certain  infections.  In  some  of  these  dis- 
eases, the  blood  pressures,  as  for  example, 
in  syphilis,  are  ordinarily  unaffected;  in 
others,  as  in  lead  poisoning,  they  are  raised. 

2.  The  class  he  calls  hyperpietic,*  in  which 
an  arteriosclerosis  is  the  consequence  of  ten- 
sile strength,  of  excessive  arterial  blood  pres- 
sure persisting  for  some  years.  A  consider- 
able example  of  this  class  is  the  arterioscle- 
rosis of  granular  kidney,  but  in  many  cases 
kidney  disease  is,  clinically  speaking,  absent. 

3.  The  involutionary  class,  in  which  the 
change  depends  upon  a  senile,  or  quasi- 
senile  degradation.  This  may  be  no  more 
than  wear  and  tear,  a  disposition  of  all  or  of 
certain  tissues  to  premature  failure — partly 
atrophic,  partly  mechanical — under  ordinary 
stresses;  or  it  also  may  be  toxic,  a  slow  poi- 
soning by  the  "faltering  rheums  of  age".  In 
ordinary  cases  of  this  class  the  blood  pres- 
sures for  the  age  of  the  patient,  are  not  ex- 
cessive. Although  the  toxins  of  the  specific 
fevers,  notably  typhoid,  as  stated  above,  and 


*  From    TtLSgcJ  to  squeeze,  straiten,  oppress  or  distress. 
Hyperpiesis,  therefore,  signifies  excessive  pressure. 


68  Arteriosclerosis 

influenza,  have  been  shown  to  produce  arte- 
riosclerosis, this,  under,  favorable  circumstan- 
ces he  believes  tends  to  disappear.  This  has 
been  shown  by  Wiesel  (v.  infra). 

As  the  blood  pressure  is  dependent  on  the 
resistance  offered  by  the  capillaries  and  arte- 
rioles, there  are  only  two  ways  in  which  in- 
creased presstue  can  be  brought  about ;  either 
by  rendering  the  blood  more  viscous,  or  by 
the  generation  of  some  poison  from  the  food 
taken  into  the  body  which,  acting  on  the  vaso- 
motor centre,  or  directly  on  the  finer  vessels, 
arteriolar  or  capillary,  sets  up  a  constriction 
over  any  large  area,  and  mainly  in  the  splanch- 
nic area.  In  regard  to  the  liability  to  arterio- 
sclerosis, this  area  stands  second  only  to  the 
aortic  and  coronary  areas.  He  believes  that 
arteriosclerosis  itself  has  little  effect  in  rais- 
ing arterial  pressure.  Many  cases  are  seen 
in  which  with  extreme  arteriosclerosis  there 
was  no  rise  in  blood  pressure,  and  some  in 
which  pressures  have  been  rising  even  long 
before  the  appearance  of  arterial  disease. 
Prof.  Allbutt  also  believes  that  in  the  hyper- 
pietic  cases  the  arteries  undergo  a  transient 


Symptoms  and  Physical  Signs  69 

thickening,  which  can  be  removed  if  the  cau- 
ses can  be  reached  and  overcome. 

CHnically  speaking,  then,  hyperpietic  ar- 
teriosclerosis is  not  a  disease  but  a  mechan- 
ical result  of  disease.  If  the  narrowing  of 
the  arterioles  is  brought  about  by  thicken- 
ing due  to  arteriosclerosis,  then  it  would  seem 
a  priori  that  such  obliteration  should  cause 
a  rise  in  pressure.  Were  the  vascular  system 
a  mere  mechanical  set  of  tubes  and  a  pump, 
this  would  happen,  but  other  factors  of  great 
importance  must  be  taken  into  consideration 
besides,  the  mechanical  factors,  viz:;  chem- 
ical and  biological  factors.  Thus,  whole 
parts  may  be  closed  and  with  compensatory 
dilatation  in  other  parts  there  would  be  little 
or  no  change  in  pressure,  unless  there  were 
hyperpiesis.  In  established  hyperpiesis,  we 
note  two  conditions  in  the  radial  artery,  first 
a  comparatively  straight  vessel  with  a  small 
diameter;  secondly,  a  larger,  more  tortuous 
vessel,  "the  large  leathery  artery."  In  the 
cases  of  the  first  group,  hyperpiesis  is  often 
more  marked,  although  not  appearing  so  to 
the  examining  finger,  than  in  the  second  class . 
In  view  of  the  difficulty  of  estimating  by 


70  Arteriosclerosis 

touch  alone  the  amount  of  hyperpiesis  in  a 
contracted  hard  artery,  it  is  often  overlooked 
until  a  ruptured  vessel  in  the  brain  startles 
us  to  a  realization  of  our  mistake.  The  "nar- 
row" artery  is  more  dangerous  than  the  tor- 
tuous one,  for  with  every  change  in  pressure 
the  passive  vessels  of  the  brain  must  receive 
blood  that  under  normal  conditions  would 
go  to  other  parts  of  the  circulation. 

In  involutionary  sclerosis  there  is  a  grad- 
ual thickening  and  tortuosity  of  the  vessel, 
which,  although  it  may  be  greater  than  in 
the  hyperpietic  cases,  yet  is  never  so  danger- 
ous to  life.  The  heart  in  hyperpiesis  hyper- 
trophies and  dilates,  but  such  a  heart  is  the 
result,  not  an  integral  part,  of  the  arterial 
disease. 


CHAPTER  VI. 

SYMPTOMS    AND    PHYSICAL    SIGNS. 

(Continued.) 

Although  arteriosclerosis  is  a  disease  which 
affects  the  whole  arterial  system,  it  never- 
theless never  reaches  the  same  grade  all  over 
the  body.  The  difference  in  the  structure 
and  functions  of  the  various  organs  deter- 
mines to  great  extent  the  eventual  sympto- 
matology. Endarteritis  obliterans  of  a  small 
sized  artery  in  the  liver  or  leg  would  lead  to 
no  marked  symptoms  as  the  circulation  is  so 
rich  that  the  anastomoses  of  the  blood  ves- 
sels would  soon  establish  a  collateral  circu- 
lation that  would  be  perfectly  competent  to 
sustain  the  function  of  the  part.  Quite  dif- 
ferent would  it  be  should  one  of  the  small  ar- 
teries of  the  brain,  the  lenticulo-striate,  for  ex- 
ample, which  supplies  the  corpus  striatum,  be- 
come the  seat  of  a  thrombosis  or  embolism 
caused  by  arteriosclerosis.  The  arteries  of 
the  brain  are  terminal  arteries  and  the  blood 
supply  would  be  cut  off  entirely  with  a  re- 
sulting anemic  necrosis  of  the  part  supplied 


72  Arteriosclerosis 

by  the  artery  and  a  loss  of  function  of  the 
part.  What  would  be  of  no  moment  in  the 
leg  or  arm,  might  prove  even  fatal  in  the 
brain. 

The  further  symptomatology,  therefore, 
of  arteriosclerosis  depends  entirely  on  the 
organ  or  organs  most  affected  by  the  inter- 
ference with  the  blood  supply.  The  follow- 
ing groups  may  be  recognized: 

1.  Cardiac 

2.  Renal 

3.  Abdominal 

4.  Cerebral 

5.  Spinal 

6.  Local  vaso-motor  effects. 

(i)  Cardiac — Most  cases  of  arterioscle- 
rosis sooner  or  later  present  symptoms  refer- 
able to  the  heart.  When  the  organ  is  hyper- 
trophied  and  is  already  working  against  an 
enormous  peripheral  resistance  a  slight  ex- 
cess of  work  put  upon  it  may  cause  a  dilata- 
tion of  the  chambers  with  the  resulting  broken 
compensation.  There  is  dyspnoea  on  slight 
exertion,  possibly  some  precordial  distress, 
slight  oedema  of  the  ankles  and  lower  legs 
and  possibly  scanty  urine.    With  proper  care, 


Symptoms  and  Physical  Signs  73 

such  a  patient  may  recover  but  the  danger 
of  another  break  in  compensation  is  enhanced. 
The  next  attack  is  more  severe.  The  oedema 
is  greater,  there  may  be  signs  of  oedema  of 
the  lungs,  effusions  into  the  serous  cavities 
may  occur.  The  heart  shows  marked  dila- 
tation. There  is  gallop  or  canter  rhythm 
and  there  are  loud  murmurs  at  the  apex. 
When  a  patient  is  first  seen  in  this  stage  it 
may  be  quite  impossible  to  state  whether  or 
not  there  is  true  valvular  disease  of  the  heart. 
The  muscle  is  usually  diseased  in  that  there 
is  fibroid  degeneration  of  more  or  less  exten- 
sive character.  This  factor  causes  the  heart 
to  lose  much  of  its  elasticity  and  increases  the 
tendency  to  permanent  dilatation.  Such 
cases  must  be  watched  before  one  can  say 
that  true  valvular  insufficiency  is  not  present. 
The  fatal  termination  of  such  a  case  is  quite 
like  that  of  true  valvular  disease.  There  is 
increasing  dyspnoea,  increasing  anasarca,  and 
the  patient  usually  succumbs  to  oedema  of 
the  lungs,   drowned  in  his  own   secretions- 

A  very  rare  complication  of  the  fibroid  de- 
generation of  the  heart  muscle  is  aneurysm 
of  the  heart  wall.     The  apex  of  the  left  ven- 


74  Arteriosclerosis 

tricle  is  most  commonly  the  site  of  the  aneu- 
rysm and  rupture  occasionally  occurs.  Such 
an  accident  is  rapidly  fatal.  In  the  arterio- 
sclerotic process  which  occurs  at  the  root  of 
the  aorta,  the  coronary  arteries  become  in- 
volved both  at  the  openings  and  along  the 
courses  of  the  vessels.  A  branch  or  branches 
or  even  one  artery  may  become  blocked  as  a 
result  of  obliterating  endarteritis.  The  ar- 
teries of  the  heart  are  terminal  vessels  and 
as  a  rule  blocking  of  them  leads  to  anemic 
infarcts.  These  areas  become  replaced  by 
fibrous  tissue  which  in  the  gross  specimen 
appears  as  streaks  of  whitish  or  yellowish 
color  in  the  musculature.  Anemic  infarcts 
may  not  occur.  If  such  is  the  case,  there 
must  be  either  abnormal  anastomotic  com- 
munications between  the  otherwise  terminal 
vessels,  or  the  circulation  is  maintained  by 
means  of  the  vessels  of  Thebesius.  Through 
arteriosclerosis  of  the  coronary  vessels  ex- 
tensive fibrous  changes  may  occur  that  lead 
to  a  myocarditis  with  its  attending  symp- 
toms— dyspnoea,  irregular  and  intermittent 
heart,  gallop  rhythm,  oedema,  etc.  One  of 
the  most  distressing  and  dangerous  results 


FIG.  Vill. 


Fig.  VIII.  Aortic  incompetence  with  hypertrophy  and 
dilatation  of  left  ventricle  the  result  of  arteriosclerosis 
afifecting  the  aortic  valves.  Note  how  the  valves  have 
been  curled,  thickened,  and  shortened,  the  edges  of  the 
valves  being  a  half  an  inch  below  the  upper  points  of  at- 
tachment. The  anterior  coronary  artery  is  shown,  the 
lumen    somewhat    narrowed.     One-quarter  size. 


Symptoms  and  Physical  Signs  75 

of  sclerosis  of  the  coronary  arteries  and  of 
the  root  of  the  aorta  is  angina  pectoris.  While 
in  almost  every  case  of  angina  pectoris  there 
is  disease  of  the  coronary  arteries,  the  con- 
trary does  not  hold  true,  for  most  extensive 
disease,  even  embolism,  of  the  arteries  is  fre- 
quently found  in  persons  who  never  suffered 
any  attacks  of  pain.  This  symptom  group 
is  more  common  in  males  than  in  females 
and  as  a  rule  occurs  only  in  adult  life.  "In 
men  under  thirty-five  syphilitic  aortitis  is 
an  important  factor."     (Osier). 

Since  the  valuable  experiments  of  Erlanger 
on  Heart  Block,  considerable  attention  has 
been  paid  to  lesions  of  the  Y-shaped  bundle 
of  fibres,  a  bundle  arising  at  the  venous  ori- 
fices in  the  right  auricle  and  extending  to  the 
two  ventricles,  known  also  as  the  auriculo- 
ventricular  bundle  of  His.  Interference  with 
the  transmission  of  impulses  through  this 
bundle  gives  rise  to  the  symptom  group 
known  as  the  Stokes- Adams  syndrome,*  which 


*  The  bundle  of  His  has  been  found  to  be  the  pathway 
through  which  the  impulses,  that  stimulate  the  heart 
muscle  to  contract,  reach  the  ventricles.  The  mechanism 
briefly  is  this.  Impulses  apparently  have  their  origin  at 
the  openings  of  the  inferior  and  superior  cava  in  the  right 


76  Arteriosclerosis 

is  characterized  by  (a)  slow  pulse,  (b)  cerebral 
attacks, — vertigo,  syncope,  transient  apop- 
lectiform and  epileptiform  seizures,  (c) 
visible  auricular  impulses  in  the  veins  of  the 
neck.  Many  of  the  cases  which  occur  are  in 
elderly  people  the  subjects  of  arteriosclerosis. 


auricle.  Contraction  of  the  heart,as  shown  by  cardiogram s 
and  cardioplethysmographs,  moves  in  a  wave  towards  the 
ventricles.  Normally  there  seem  to  be  several  stimuli 
originating  at  the  venous  orifices,  all  of  which,however,  do 
not  reach  the  ventricles.  There  is,  moreover,  a  definite 
ratio  between  the  number  of  stimuli  and  the  actual  number 
of  ventricular  contractions.  These  may  be  4:1,  3:1,  2:1, 
1:1.  Thus  it  is  clear  that  there  may  be  4,  3,  2,  1  auricular 
contractions  to  one  ventricular  contraction.  Now  by 
experimentally  compressing  the  heart  of  the  dog  at  the 
auriculo-ventricular  ring  by  means  of  a  special  clamp 
there  is  marked  disturbance  in  the  relation  of  the  auricular 
and  ventricular  contractions.  This  blocking  of  impulses 
may  be  carried  on  to  the  extent  that  the  auricles  and 
ventricles  beat  absolutely  independently  of  one  another. 
Slight  blocking  may  give  extra  systolic  beats  heard  at  the 
heart  but  not  felt  in  the  pulse. 

In  Stokes-Adams  syndrome  we  find  that  lesions  of  the 
bundle  of  His  give  us  much  the  same  phenomena  as  we  can 
experimentally  produce  on  animals  by  actual  compression 
of  the  bundle. 

Those  interested  in  further  information  may  find  it  by 
consulting  articles  by  Erlanger,  Dawson,  Hirschfelder, 
Hev,'lett,  etc.,  in  Jour.  Exper.  Med.,  Brit.  Med.  Jour.,  Am. 
Jour.  Med.  Sc,  Jour.  Amer.  Med.  Assoc,  Johns  Hopkins 
Hospital  Bulletin,  etc.  All  the  literature  is  contained  in 
articles  written  during  the  past  four  years. 


Symptoms  and  Physical  Signs  77 

There  is  disease  of  the  bunde  of  His  (auri- 
culo-ventricular  bundle)  in  cases  recently 
carefully  examined.  G.  C.  Robinson  in  a 
collection  of  i6  cases  found  most  of  them  due 
to  gummatous  lesions  of  the  bundle,  some 
however,  were  arteriosclerotic  in  type.  The 
condition  is  most  interesting  and  careful 
autopsies  should  be  made  on  all  those  dying 
with  symptoms  of  Stokes- Adams  disease. 

Renal — There  are  those  who  see  in  in- 
creased arterial  tension  renal  disease  alM'^ays 
manifest  or  latent.  While  it  is  a  valuable 
observation  that  persistent  high  tension  is 
very  frequently  the  warning  sign  of  a  begin- 
ning chronic  nephritis,  one  cannot  say  that 
such  is  always  the  case.  We  frequently  see 
elderly  patients  in  whom  there  is  high  tension 
and  some  arteriosclerosis  of  the  palpable  arte- 
ries, but  in  whose  urines  repeated  examinations 
fail  to  reveal  the  slightest  evidence  of  renal 
disease.  Such  kidneys  are  small  and  granular, 
to  be  sure;  they  are  known  as  the  senile 
kidney.  The  connective  tissue  is  increased 
and  there  is  also  throughout  the  body, 
evidence  of  senile  atrophy.  Such  kidneys 
connot  strictly  be  said  to  be  diseased  even 


78  Arteriosclerosis 

though  they  may  appear  much  hke  the  kid- 
neys of  much  younger  persons  who  have  died 
from  definite  chronic  nephritis.  However, 
in  a  large  number  of  cases  of  arteriosclerosis 
renal  symptoms  appear.  There  is  oedema 
of  the  ankles  and  legs,  puffiness  of  the  eyelids, 
anemia,  etc.  There  may  be  uremic  amau- 
roris,  uremic  convulsions,  or  symptoms  of 
mild  uremia,  such  as  headache,  transient 
attacks  of  blindness,  dizziness,  vertigo,  etc. 
It  is  not  possible  always  in  a  given  case  to 
decide  whether  the  arterial  or  the  renal  dis- 
ease was  the  primary  one.  Clinically  the 
question  is  not  of  such  great  importance,  as 
the  end  results  are  practically  the  same  which- 
ever system  was  first  involved,  where  symp- 
toms of  both  put  in  their  appearance. 

AbdominaIv  or  Viscerai. — There  is  an 
important  group  of  cases  to  which  but  little 
attention  has  been  paid  until  quite  recently. 
This  is  the  abdominal  or  visceral  type  of 
arteriosclerosis.  It  has  been  stated  that 
arteriosclerosis  of  the  splanchnic  vessels 
almost  invariably  causes  high  tension. 
Among  others,  Jane  way  has  shown  that  general 
arteriosclerosis   without   marked   disease   of 


Symptoms  and  Physical  Signs  79 

the  splanchnic  vessels  does  not  cause  as   a 
nile  increase  of  blood  pressure. 

There  are  cases  in  which  the  brunt  of  the 
lesion  falls  upon  the  abdominal  vessels.  Such 
cases  have  been  called  "Angina  abdomin- 
alis".  It  has  been  suggested  (Harlow 
Brooks)  that  this  type  of  arteriosclerosis  may 
be  determined  by  constant  overloading  of 
the  stomach  with  food,  especially  rich  and 
spiced  food.  This  causes  overwork  of  the 
special  arteries  connected  with  digestion  and 
so  leads  to  sclerosis  of  the  vessels  of  the 
stomach,  pancreas,  and  intestines.  Personal 
habits  probably  influence  to  great  extent 
the  production  of  this  more  or  less  localized 
condition. 

The  organs  supplied  by  the  diseased 
arteries  suffer  from  changes  analogous  to 
those  occuring  in  general  or  local  malnu- 
trition, such  as  starvation,  old  age,  or  local 
anemias.  These  changes  are  atrophy  with 
hemachromatosis  (brown  atrophy)  or  fatty 
infiltration  and  degeneration.  Following  the 
degenerative  changes  there  result  connective 
tissue  growth  and  further  limitation  of  the 
functioning  power   of  the   affected  organs. 


80  Arteriosclerosis 

Pain  is  a  more  or  less  constant  symptom 
of  visceral  sclerosis.  In  the  early  stages  there 
may  be  only  a  sense  of  oppression,  of  weight, 
or  of  actual  pressure  in  the  abdomen  or  pit 
of  the  stomach.  There  may  be  only  recur- 
ring attacks  of  violent  abdominal  pain  accom- 
panied by  vomiting.  In  some  cases  symp- 
toms of  tenderness  in  the  epigastrium,  pains 
in  the  stomach  after  eating,  vomiting  and 
backache  may  suggest  gastric  ulcer.  There 
may  be  dyspnoea  and  a  sense  of  anguish 
accompanied  with  a  rapid  and  feeble  pulse. 
Hematemesis  may  make  the  symptom  group 
even  more  like  ulcer  of  the  stomach,  and  only 
the  course  of  the  disease  with  the  failure  of 
rigid  ulcer  treatment  and  the  substitution 
of  treatment  directed  towards  relief  of  the 
arterial  spasm  with  resulting  betterment, 
enables  one  to  make  a  diagnosis.  The  condition 
may  be  present  for  years  and  the  symptoms 
only  epigastric  tenderness  with  dizziness 
and  sweating  on  lying  down  after  dinner,  as 
in  one  of  Perutz's  patients.  The  attacks  are 
probably  due  to  spasmodic  contraction  of 
the  sclerosed  intestinal  vessels  with  a  result- 
ing local  rise  in  blood  pressure.     The  pains 


Symptoms  and  Physical  Signs  81 

are  probably  located  in  the  sympathetic  and 
mesenteric  plexuses. 

This  result  of  arteriosclerosis  is  not  so 
uncommon,  and  by  keeping  this  cause  of 
obscure  abdominal  pain  in  mind  we  are  now 
and  then  enabled  to  save  a  patient  from 
operation. 

The  following  case  reported  by  Neusser 
will  serve  as  a  good  example  of  this  so-called 
angina  pectoris  gastralgica. 

Iv.  G.  47  years  old,  married,  letter  carrier, 
adm.  June  12,  1902.  The  patient  had  had 
malaria.  At  30  and  40  yrs.  he  had  ischias; 
suffered  much  from  eructations  and  when 
42  had  catarrh  of  the  stomach,  which  was  the 
beginning  of  his  present  illness,  and  for  which 
he  underwent  a  rigid  diet  and  Carlsbad  water 
cure. 

On  admission,  he  complained  that  when 
he  returned  home  after  work,  he  suddenly 
experienced  a  burning  and  a  feeling  of 
oppression  in  the  stomach,  he  could  not 
breathe  freely,  but  during  the  pain  had  to 
remain  standing  and  take  short,  quick 
breaths.  Such  an  attack  lasted  about  a 
minute,  then  he  could  go  on.     This  sort  of 


82  Arteriosclerosis 

attack  was  repeated  every  8  to  14  days. 
In  summer,  he  had  fewer  attacks,  in  fall  they 
became  more  frequent  and  especially  frequent 
and  severe  in  winter.  Between  attacks  he 
felt  quite  well,  could  eat  anything,  had  no 
eructations,  no  vomiting.  Recently  the 
attacks  had  become  more  frequent  and  more 
severe.  Milder  attacks  began  with  a  drawing 
pain  in  the  pit  of  the  stomach  and  a  feeling 
of  fulness  in  the  stomach.  As  soon  as  the 
attack  ceased  there  was  some  belching  and 
then  relief  was  felt.  When  the  attack  came 
on  shortly  after  eating,  there  followed  trouble- 
some vomiting  and  then  relief.  Severe 
attacks  began  with  burning  pain  in  the  stomach 
located  deeply,  which  radiated  outwards 
over  the  chest  to  the  manubrium  sterni,  with 
a  feeling  in  the  larynx  as  if  the  parts  were 
being  screwed  together,  violent  pain,  that 
extended  fromthe  neck  over  both  under  jaws 
to  the  temples,  at  the  same  time  there  followed 
sweating  and  salivation  now  and  again  and 
also  radiation  of  the  pain  to  the  teeth. 

In  especially  severe  attacks  the  pain  was 
felt  between  the  shoulders  as  a  band  around 
the   chest;   deep   breathing   was  impossible. 


Symptoms  and  Physical  Signs  S3 

Following  the  attacks  there  was  great  weak- 
ness. Actual  feelings  of  impending  dissolu- 
tion the  patient  never  had,  likewise  no  stream- 
ing pains  in  the  left  or  right  shoulders,  in  the 
arm  or  below;  no  dizziness,  no  palpitation. 
The  pulse  showed  no  abnormality  during  the 
four  to  fifteen  minute  attacks. 

The  exciting  causes  of  the  attacks  recently 
were  many.  Not  only  walking  but  also  lifting, 
psychic  exertions  especially  at  his  work, 
changes  of  temperature,  e.  g.,  leaving  a  hot 
room  in  winter  for  the  outside  cold,  would 
bring  on  attacks.  Especially  easily  were 
attacks  brought  on  by  taking  spicy  foods, 
cheese,  wine,  whiskey.  In  the  intervals  he 
felt  well,  had  a  good  appetite,  the  bowels 
were  regular.  He  was  a  moderate  drinker 
and  smoker.  He  had  had  gonorrhoea  at  22 
years;  a  soft  chancre  at  23,  no  skin  eruptions. 

P.  E. — He  is  a  well  built  man,  the  pupillary 
reaction  is  prompt,  the  patellar  reflexes  are 
normal.  The  mucous  membranes  are 
somewhat  livid,  the  skin  is  slightly  icteric. 
There  is  visible  pulsation  at  the  jugular 
notch;  the  arteries  are  not  hard.  The 
sphygmomanometer  (Basch)  reading  is  115; 


84  Arteriosclerosis 

pulse  72;  the  lungs  are  normal.  The  point 
of  maximum  impulse  of  the  heart  is  palpable 
in  5th  interspace,  somewhat  displaced  out- 
wards ;  the  dulness  reaches  on  right  to  sternal 
border.  The  second  aortic  is  ringing;  after 
the  sound  there  is  a  diastolic  murmur  which 
is  transmitted  downwards  as  far  as  the 
xiphoid.  Posteriorly  to  the  left  from  the 
spine  the  diastolic  murmur  and  the  second 
ringing  tone  are  plainly  heard. 

Diagnosis:  Sclerosis  of  the  thoracic  aorta 
and  insufficiency  of  the  aortic  valve.  Angina 
pectoris  coronaria. 

On  July  26th  the  patient  left  the  hospital 
much  improved. 

Cerebral  —  It  has  been  stated  that 
arteriosclerosis  is  a  general  disease  yet  certain 
systems  of  vessels  may  be  affected  far  more 
than  others  and  indeed  there  may  be  marked 
sclerosis  at  one  part  of  the  body  and  none 
demonstrable  at  another  part. 

In  advanced  sclerosis  there  may  be  one  or 
more  of  a  series  of  accidents  due  to  embolism, 
thrombosis,  or  rupture  of  the  vessels.  Such 
conditions  as  transient  hemiplegia,  mono- 
plegia or  aphasia  may  occur.     The  attacks 


Symptoms  and  Physical  Signs  85 

may  come  on  suddenly  and  be  over  in  a  few 
minutes;  what  Allbutt  calls  "Larval  apo- 
plexies ' ' .  They  may  last  from  a  few  hours  up 
to  a  day;  they  are  very  characteristic.  A  pa- 
tient aged  64  years  with  pipestem  radials  and 
tortuous  hard  temporals  would  be  lying 
quietly  in  bed  when  suddenly  he  would  stiffen, 
the  eyes  would  become  fixed  and  the  breath- 
ing cease.  In  a  few  seconds  consciousness  re- 
turned, the  patient  would  shake  himself ,  pass 
his  hand  over  his  brow  and  ask  "Where  am  I? 
Oh,  yes,  that's  all  right".  He  had  as  many  as 
thirty  of  these  attacks  in  twenty-four  hours, 
none  of  them  lasting  over  one  minute.  Just 
what  such  attacks  are  due  to  it  is  hard  to  say. 
Some  have  attributed  them  to  spasm  of  the 
smaller  blood  vessels  of  the  brain,  but  there 
have  never  been  demonstrated  in  the  vessels 
any  constrictor  fibres. 

There  is  a  well  recognized  form  of  dementia 
caused  by  arteriosclerosis.  In  general 
paralysis  of  the  insane  and  in  senile  dementia 
the  blood  vessels  are  always  diseased.  Milder 
grades  of  psychic  disturbances  are  accom- 
panied by  such  symptoms  as  mental  fatigue, 
persistent     headaches,      vertigo,     memory 


86  Arteriosclerosis 

weakness  and  fainting.  Aphasia,  periods  of 
excitement  and  mental  confusion  occur  in 
some.  Later  stages  are  at  times  accompanied 
by  inclination  to  fabulate,  loss  of  judgement, 
disorientation,  narrowing  of  the  external 
interests,  episodes  of  confusion  and  hallucina- 
tory delirium. 

The  hemiplegias,  monoplegias  and  para- 
plegias may  occur  again  and  again  and  last 
for  one  or  two  days.  Unless  there  has  been 
rupture  of  the  vessels  there  is  complete  re- 
covery as  a  rule. 

In  persons  who  have  arteriosclerosis  with 
high  tension  attacks  of  melancholia  are  seen. 
There  are  at  the  same  time  fits  of  depression, 
insomnia,  irritability,  fretfulness  and  a  gen- 
erally marked  change  in  disposition.  When 
the  tension  is  reduced  by  appropriate  treat- 
ment these  symptoms  disappear,  to  recur 
when  the  tension  again  becomes  high.  On 
the  contrary  attacks  of  mania  are  accom- 
panied by  low  blood  preasure.  The  dizziness 
and  vertigo  in  cerebral  arteriosclerosis  are 
probably  due  to  the  stiffness  of  the  vessels 
which  prevents  them  from  following  closely 
the    variations     of    pressure    produced    by 


Symptoms  and  Physical  Signs  87 

position,  and  thus,  at  times,  the  brain  is  de- 
prived of  blood  and  a  transient  anemia 
occurs. 

In  Stokes-Adams  syndrome  the  slow  pulse 
is  due  as  has  been  stated  to  some  lesion  of  the 
auriculo-ventricular  muscle  bundle  in  the 
heart.  The  epileptiform  and  apoplectiform 
attacks  which  occur  are  due  to  the  sclerosis  of 
the  cerebral  vessels .  In  a  case,  seen  by  the  wri- 
ter, of  a  colored  man  thirty-two  years  of  age 
who  gave  a  history  of  syphilis,  the  cerebral 
sclerosis  as  well  as  the  lesion  in  the  heart  was 
in  all  probability  due  to  the  syphilitic  toxin. 

Arteriosclerosis  of  the  cerebral  vessels  is 
always  a  serious  condition.  The  greatest 
danger  is  from  rupture  of  a  blood  vessel. 
Another  of  the  dangers  is  gradual  occlusion 
of  the  arteries  bringing  about  necrosis  with 
softening  of  the  brain  substance.  The  latter 
is  more  apt  to  be  associated  with  psychic 
changes,  dementia,  etc.;  the  former,  with 
hemiplegia.  It  is  curious  that  a  small  branch 
of  the  Sylvian  artery,  the  lenticulostriate, 
which  supplies  the  corpus  striatum,  should  be 
the  one  which  most  frequently  ruptures. 
Where   the   motor   fibres   from   the   whole 


S8  Arteriosclerosis 

cortex  are  gathered  together  in  one  compact 
bundle  a  very  small  hemorrhage  may  and 
does  cause  very  serious  effects.  A  compara- 
tively large  hemorrhage  in  the  silent  area  of 
the  brain  may  cause  few  or  no  symptoms. 

Spinai^ — It  is  conceivable  that  arterio- 
sclerosis of  the  vessels  of  the  spinal  cord 
might  cause  symptoms  which  would  be  re- 
ferred to  the  areas  of  the  cord  where  the 
process  was  most  advanced.  The  lesions 
would  be  scattered  and  consequently  the  symp- 
toms might  be  protean  in  character. 

True  epileptic  convulsions  dependent  on 
arteriosclerotic  changes  are  also  seen  and  are 
not  so  uncommon. 

This  is  on  the  whole  a  rare  condition,  much 
less  common  than  arteriosclerosis  of  the 
cerebral  vessels.  Collins  and  Zabriskie  report 
the  following  typical  case : 

"H.,  a  fireman  ,51  yrs.old,was  in  ordinary 
good  health  until  toward  the  end  of  1 902 .  At 
that  time  he  noticed  that  his  legs  were  grow- 
ing weak  and  that  they  tired  easily.  Later 
he  complained  of  a  jerking  sensation  in  dif- 
ferent parts  of  the  lower  extremities  and  at 
times  of  sharp  pain,  which  might  last  from 


Symptoms  and  Physical  Signs  89 

several  minutes  to  two  or  three  hours.  The 
legs  were  the  seat  of  a  heavy,  unwieldly  sen- 
sation, but  there  was  no  numbness  or  other 
paresthesia.  About  the  same  time  he  began 
to  have  difficulty  in  holding  the  urine,  a 
symptom  which  steadily  increased  in  sever- 
ity. These  symptoms  continued  until  March 
1903,  i.  e.,  for  three  months,  then  he  awak- 
ened one  morning  to  find  that  he  was  unable 
to  stand  or  walk,  and  the  sphincters  of  the 
bowels  and  bladder  relaxed.  There  was  no 
complaint  of  pain  in  the  back  or  legs,  no 
difficulty  in  moving  the  arms,  in  swallowing 
or  in  speaking.  He  says  he  was  able  to  tell 
when  his  lower  extremities  were  touched  and 
he  could  feel  the  bed  and  clothes.  He  was 
admitted  to  the  City  Hospital  three  weeks 
later  and  the  following  record  was  made  on 
April  21,  1903. 

The  patient  was  a  frail,  emaciated  man  of 
medium  height,  who  had  the  appearance  of 
being  55-60  yrs.  of  age..  He  was  unable  to 
stand  or  walk.  When  he  was  lying  he 
could  flex  the  thigh  and  the  legs  slowly  and 
feebly.  There  was  slight  atrophy  of  the  an- 
terior and  inner  muscles,  more  of  the  left  than 


90  Arterioslcerosis 

of  the  right  side.  The  knee  jerks  and  ankle 
jerks  were  absent.  Irritation  of  the  soles 
caused  quite  a  typical  Babinski  phenomenon. 
The  patient  had  fair  strength  in  the  upper 
extremities,  but  the  arms  tired  very  soon,  he 
said.  The  grip  was  moderate  and  alike  in 
each  hand.  The  motility  of  the  face,  head^ 
and  neck  was  not  noticeably  impaired. 
There  was  no  difficulty  in  swallowing,  and 
articulation  was  not  defective.  Tactile  sensi- 
bility was  slightly  disordered  in  the  lower 
extremities,  although  he  could  feel  contact  of 
the  finger,  the  point  of  a  pin,  and  the  like. 
Sensibility  was  not  so  acute  as  normal;  there 
was  a  quantitative  dimunition.  Sensory 
perception  was  not  delayed.  There  was  a 
distinct  zone  of  slight  hyperesthesia  about  as 
wide  as  the  hand  above  the  femoral  troch- 
anters. Above  that,  sensibility  was  normal. 
There  was  no  discernible  impairment  of 
thermal  sensibility.  No  part  of  the  body  was 
particularly  tender  on  pressure.  A  bedsore 
existed  over  the  sacrum,  and  there  was  ex- 
coriation of  the  genitals  from  constant  drib- 
bling of  urine. 


Symptoms  and  Physical  Signs         91 

Examination  of  the  chest  showed  shallow 
respiratory  movements.  The  heart  was 
regular,  weak,  there  were  no  murmurs,  the 
second  sound  was  accentuated.  Examin- 
ation of  the  abdomen  showed  that  the  liver 
and  spleen  were  palpable,  but  were  not  en- 
larged. The  abdominal  reflexes,  both  upper 
and  lower,  were  sluggish.  The  patient  was 
slow  of  speech,  likewise  apparently  of  thought. 
He  did  not  seem  to  show  an  adequate  interest 
in  his  condition,  still  he  was  fully  oriented  and 
seemed  to  have  a  fair  memory.  His  mental 
reflex  was  slow.  There  were  indications  in 
the  peripheral  blood  vessels  and  heart  of  a 
moderate  degree  of  general  arteriosclerosis. 
The  peripheral  vessels,  such  as  the  radial, 
were  palpable,  the  walls  thickened,  the  blood 
pressure  increased. 

The  patient  did  not  complain  of  pain 
while  he  was  in  the  hospital,  a  period  of  four 
weeks,  nor  was  there  any  particular  change 
in  the  patient's  symptoms,  subjective  and  ob- 
jective, during  this  time.  His  mental  state  re- 
mained clear  until  forty-eight  hours  before 
death,  when  he  became  sleepy,  stuporous,  and 
comatose,  dying  apparently  of  cardiac  weak- 


92  Arteriosclerosis 

ness,  which  had  set  in  simultaneously  with 
the  clouding  of  consciousness. ' ' 

At  autopsy,  except  for  a  few  small  hemor- 
rhages in  the  posterior  horns  of  the  lower 
dorsal  segments  on  the  right  side  and  a  sim- 
ilar condition  of  the  left  anterior  horn,  there 
was  nothing  noticed.  On  microscopical  ex- 
amination, there  was  widespread  sclerosis  of 
the  vessels  of  the  cord  of  a  marked  degree 
with  only  slight  thickening  of  the  vessels  of  the 
brain.  There  were  secondary  degenerations 
of  ascending  and  descending  type  partic- 
ularly marked  at  the  ninth  dorsal  segment. 
They  included  portions  of  all  the  tracts,  the 
pyramidal  tract  as  well.  The  symptoms 
in  brief  were:  (i)  Weakness  and  easily  in- 
duced fatigue  of  the  legs;  (2)  peculiar  sen- 
sations in  the  lower  extermities,  described  as 
jerky,  numbness,  heaviness,  and  occasionally 
sharp  pain;  (3)  progressive  incontinence  of 
urine;  (4)  progressive  paraplegia. 

Local  or  peripheral — ^When  the  arterio- 
sclerosis in  the  peripheral  arteries  reaches  a 
stage  where  endarteritis  obliterans  super- 
venes, there  is  usually  no  chance  for  a  com- 
pensatory or  collateral  circulation  to  be  estab- 


Symptoms  and  Physical  Signs  93 

lished.  The  area  supplied  by  the  vessel 
undergoes  dry  gangrene.  A  portion  of  a  toe 
or  finger  or  a  whole  foot  or  hand  may  shrivel 
up.  It  is  more  common  to  see  the  spon- 
taneous amputation  take  place  in  the  lower 
extremities.  The  same  effect  may  be  pro- 
duced by  the  plugging  of  a  vessel  with  a 
thrombus.  There  may  be  much  pain  con- 
nected with  the  sudden  blocking,  whereas  the 
gradual  obliteration  of  the  blood  supply  of  a 
toe  or  foot  is  not  as  a  rule  at  all  painful.  The 
condition  is  at  times  revealed  more  or  less 
accidentally  when  a  patient  injures  his  toe 
or  foot  and  discovers  that  there  is  no  sen- 
sation to  the  part  and  that  the  wound  instead 
of  healing  is  inclined  to  grow  larger. 

Other  interesting  vasomotor  phenomena 
are  frequently  connected  with  arterio- 
sclerosis. Such  a  one  is  the  curious  con- 
dition known  as  Raynaud's  disease,  a  vascu- 
lar disorder  which  is  divided  into  three  grades 
of  intensity:  (i)  local  syncope,  (2)  local 
asphyxia,  (3)  local  or  symmetrical  gangrene. 
This  is  not  the  place  to  describe  this  condition 
except  to  say  that  the  condition  called  "dead 
fingers ' '  is  the  most  characteristic  feature  of 


94  Arteriosclerosis 

the  first  stage.  Chilblains  represent  the  mil- 
dest grade  of  the  second  stage.  The  parts 
are  intensely  congested  and  there  may  be 
excruciating  pain.  Anyone  who  has  ever  had 
chilblains  knows  how  painful  they  can  be. 
The  general  health  is  not  impaired  as  a  rule, 
although  the  attacks  are  apt  to  come  on 
when  the  person  is  run  down.  The  third 
stage  may  vary  from  a  very  mild  grade,  with 
only  small  necrotic  areas  at  the  tips  of  the 
fingers,  to  extensive  multiple  gangrene. 

Another  and  very  rare  condition  in  which 
chronic  endarteritis  was  the  only  constant 
finding  is  the  disease  discribed  by  S.  Weir 
Mitchell  and  called  by  him  erythromelalgia 
(red  neuralgia.)  This  is  "A  chronic  disease 
in  which  a  part  or  parts — usually  one  or 
more  extremities — suffer  with  pain,  flushing, 
and  local  fever,  made  far  worse  if  the  parts 
hang  down."     (Weir  Mitchell). 

Probably  the  most  frequently  seen  result 
of  arteriosclerosis  in  the  leg  arteries  is  the 
remarkable  condition,  first  described  by 
Charcot,  known  as  intermittent  claudica- 
tion. Persons  the  subject  of  this  disease 
are  able  to  walk  if  they  go  slowly.     If,  how- 


Symptoms  and  Physical  Signs  95 

ever,  any  attempt  be  made  to  hurry  the  step, 
there  results  total  disability  accompanied  at 
times  by  considerable  cramp-like  pain.  The 
condition  is  much  more  prone  to  occur  in 
men  than  in  women,  and  Hebrews  seem  more 
frequently  affected.  The  cause  is  most  prob- 
ably to  be  sought  in  the  anemia  which  results 
from  the  narrowing  of  the  channels  through 
which  the  blood  reaches  the  part.  The  stiff, 
much  narrowed  arteries  allow  sufficient  blood 
to  pass  along  for  the  nutrition  of  the  part  at 
rest  or  in  quiet  motion.  Just  as  soon  as 
more  violent  exercise  is  taken,  calling  for 
more  blood,  an  ischemia  of  the  part  super- 
venes, for  the  stiff  vessels  cannot  accomodate 
themselves  to  changes  in  the  necessary  vas- 
cularity of  the  part.  A  rest  brings  about  a 
gradual  return  of  blood  and  the  function  of 
the  part  is  restored.  Pulsation  may  be  to- 
tally absent  in  the  dorsal  arteries  of  the  feet 
and  when  the  legs  are  allowed  to  hang  down 
there  is  apt  to  be  deep  congestion. 

In  this  connection  a  curious  case  reported 
by  Parkes  Weber  will  not  be  out  of  place. 
The  patient,  a  male,  aged  42  years  complained 
of  cramp-like  pains  in  the  sole  of  the  left  foot 


96  Arteriosclerosis 

and  calf  of  the  leg  occurring  after  walking 
for  a  few  minutes  and  obliging  him  to  rest 
frequently.  When  the  legs  were  allowed 
to  hang  over  the  side  of  the  bed,  the  distal 
portion  of  the  left  foot  became  red  and  con- 
gested looking.  No  pulsation  could  be  felt 
in  the  dorsal  artery  of  the  left  foot  or  in  the 
posterior  tibial  artery.  There  was  no  evi- 
dence of  car dio- vascular  or  other  disease. 
An  ulcer  on  the  little  toe  had  slowly  healed, 
but  cramplike  muscular  pains  still  occurred 
on  walking.  The  disease  had  lasted  about 
five  years  without  the  appearance  of  gangrene. 
Weber  calls  this  case  one  of  arteritis  ob- 
literans with  intermittent  claudication. 


CHAPTER  VII. 

DIAGNOSIS  AND  DIFFBRBNTIAI. 
DIAGNOSIS. 

Arteriosclerosis  is  essentially  a  disease  of 
middle  life  and  old  age;  only  rarely  do  we 
see  it  in  persons  under  forty  years  of  a^^e. 

The  diagnosis  of  arteriosclerosis  may  be 
so  easily  made  that  the  tyro  could  not  fail 
to  make  it.  It  is,  however,  the  purpose  of 
this  volume  to  lay  stress  on  the  earliest  pos- 
sible diagnosis  and,  if  possible,  to  point  out 
how  the  diagnosis  may  be  arrived  at.  It  is 
obviously  much  to  the  advantage  of  the  pa- 
tient to  know  that  certain  changes  are  be- 
ginning in  his  arteries,  that,  if  allowed  to  go 
on,  will  inevitably  lead  to  one  or  more  of  the 
symptom  groups  described  in  the  preceding 
chapters. 

The  combination  of  (i)  hypertrophied 
heart,  (2)  increased  blood  pressure,  (3)  pal- 
pable arteries,  and  (4)  ringing,  accentuated 
second  sound  at  the  aortic  cartilage  is  in,  re- 
ality, the  picture  of  advanced  arteriosclerosis. 
If  the  individual  is  in  good  condition  much 


98  Arteriosclerosis 

may  be  done  by  judicious  advice  and  treat- 
ment to  ward  off  complications  and  pro- 
long life  with  a  considerable  degree  of  com- 
fort. But  we  should  not  wait  until  such 
signs  are  found  before  making  a  diagnosis 
and  instituting  treatment.  As  in  all  forms 
of  chronic  disease  the  early  diagnosis  is  all 
important. 

The  history  of  the  case  is  the  first  essential. 
Often  a  careful  inquiry  into  the  personal 
habits  of  a  patient,  with  the  record  of  all  the 
preceding  infectious  diseases  will  give  us  val- 
uable information  and  may  be  the  means  of 
directing  the  attention  at  once  to  the  possi- 
ble true  condition.  Particularly  must  we 
inquire  into  the  family  history  of  gout  and 
rheumatism.  An  individual  who  comes  of 
gouty  stock  is  certainly  more  prone  to  arte- 
rial degeneration  than  one  who  can  show  a 
healthy  heredity.  Alcoholism  in  the  family 
also  is  of  importance  because  of  the  fact  that 
the  children  of  alcoholics  start  in  life  with  a 
poor  quality  of  tissue,  and  conditions  that 
would  not  affect  a  man  from  healthy  stock 
might  cause  early  degeneration  of  arterial 
tissue  in  one  of  bad  ancestry. 


Diagnosis  and  Differential  Diagnosis.   99 

What  infectious  diseases  has  the  patient 
had?  Even  the  exanthemata  may  cause  de- 
generations in  the  arteries,  but,  as  has  been 
shown,  such  lesions  probably  heal  completely 
with  no  resulting  damage  to  the  vessel. 
Should  the  patient  have  passed  through  a 
long  siege  of  typhoid  fever  the  problem  is 
quite  different.  Here,  (vide  supra)  (Thayer) 
the  palpable  arteries  do  appear  to  be  scle- 
rosed permanently.  Probably  the  length 
of  time  that  the  toxin  has  had  a  chance  to 
act  determines  the  permanent  damage  to 
the  vessel  wall.  More  potent  than  all  other 
diseases  to  cause  early  arteriosclerosis  is 
syphilis,  and  hence  very  careful  inquiry 
should  be  made  in  regard  to  the  possibility 
of  infection  with  this  virus.  Not  only  the 
fact  of  actual  infection  but  the  duration  and 
thoroughness  of  treatment  are  important  mat- 
ters for  the  physician  to  know. 

What  is  the  patient's  occupation?  Has  he 
been  an  athlete,  particularly  an  oarsman,  has 
he  been  under  any  severe,  prolonged,  mental 
strain?  Is  he  a  laborer?  If  so,  what  form  of 
manual  labor  is  he  engaged  in?  Such  ques- 
tions as  these  should  never  be  overlooked  as 


100  Arteriosclerosis 

they  form  the  foundation  stones  of  an  ac- 
curate diagnosis  and  early,  accurate  diag- 
nosis, we  repeat,  is  essential  to  successful 
therapy. 

We  have  called  attention  to  the  fac- 
tor of  sustained  high  pressure  in  the  pro- 
duction of  arteriosclerosis.  Constant  over- 
stretching of  the  vessels  leads  to  efforts  of 
the  body  to  increase  the  strength  of  the  part 
or  parts.  The  material  which  is  used  to 
strengthen  the  weakened  walls  has  a  higher 
elastic  resistance  than  muscle  and  elastic 
tissue,  but  a  lower  limit  of  elasticity,  and  is 
none  other  than  the  familiar  connective  tissue. 
In  athletes,  laborers,  brain  workers  who  are 
under  constant  mental  strain,  and  in  those 
whose  calling  brings  them  into  contact  with 
such  poisons  as  lead,  there  is  every  factor  ne- 
cessary for  the  production  of  high  tension  and 
consequently  of  arteriosclerosis. 

Another  question  in  regard  to  personal 
habits  is  how  much  tobacco  does  the  patient 
use  and  in  what  form  does  he  use  it?  Our 
experience  is  that  the  cigar  smoker  is  more 
prone  to  present  the  symptoms  of  arterioscle- 
rosis than  the  cigarette  smoker,  the  pipe  smo- 


Diagnosis  and  Differential  Diagnosis  101 

ker  or  the  one  who  chews  the  tobacco.  A 
very  irritable  heart  results  not  infrequently 
from  cigarette  smoking  but  such  is  almost  al- 
ways found  in  young  men  in  whom  the  lesions 
of  arteriosclerosis  are  exceedingly  rare.  The 
probabilities  are  that  the  arteriosclerosis  in 
cigar  smoking  results  from  the  slowly  acting 
poison  which  causes  a  rapid  heart  rate  with 
an  increase  of  pressure. 

Last  but  not  least,  and  perhaps  the  most  im- 
portant question  is,  has  the  patient  been  a 
heavy  eater?  This  we  believe  to  be  a  potent 
cause  of  splanchnic  arteriosclerosis  with  the 
resulting  indigestion,  cramplike  attacks,  high 
blood  pressure,  etc.  In  a  joking  manner  we 
are  accustomed  to  remark  "Overeating  is  the 
curse  of  the  American  people. ' '  There  is 
however  much  truth  in  that  sentence.  Osier, 
than  whom  there  is  no  keener  observer, 
states  that  he  is  more  and  more  impressed 
with  the  fact  that  overloading  the  stomach  with 
rich  or  heavy  or  spiced  foods  is  today  one 
of  the  first  causes  of  arterial  degeneration. 
It  stands  to  reason  that  this  is  true.  We 
know  that  organs  exposed  constantly  to  hard 
work  undergo  hypertrophy,  and  that  the  blood 


102  Arteriosclerosis 

tension  in  those  organs  is  high.  Blood  tension 
is,  after  all,  dependent  on  capillary  resistance, 
and  if  the  capillaries  are  distended  with  blood, 
the  resistance  is  great.  The  digestive  organs 
can  be  no  exception  to  this  rule.  Increased 
work  means  an  increase  of  blood.  This  in- 
evitably causes  distension  of  the  capillaries 
with  stretching  of  the  arteries  and  consequent 
damage  to  the  walls.  Once  arteriosclerosis 
is  present  a  vicious  circle  is  established. 

A  man  about  forty-five  consults  us  and 
says  that  he  has  noticed  recently  that  he  gets 
out  of  breath  easily;  in  tying  his  shoes  he 
experiences  some  dizziness.  He  finds  that  he 
has  palpitation  of  the  heart  and  possibly  pain 
over  the  precordial  region  now  and  then.  He 
notices  also  that  he  is  irritable,  that  is  his 
family  tell  him  he  is,  and  he  notices  that 
things  that  did  not  use  to  annoy  him,  now 
are  almost  hateful  to  him.  On  examination, 
one  finds  a  palpable  radial,  a  somewhat  hyper- 
trophied  heart  and  slightly  accentuated  second 
aortic  sound.  The  blood  pressure  may  be 
high.  The  urine  may  or  may  not  reveal  any 
abnormalities.  Not  infrequently,  although 
no  albumen  may  be  found,  there  are  hyaline 


Diagnosis  and  Differential  Diagnosis  103 

casts.  Such  a  case  of  arteriosclerosis  is  evi- 
dently not  to  be  regarded  as  early.  Then 
the  question  arises  how  are  we  to  recog- 
nize early  arteriosclerosis  ?  I  do  not  believe 
that  the  solution  of  this  problem  lies  entirely 
in  the  hands  of  the  physician.  Some  men 
are  fortunate  enough  to  come  up  for  an 
examination  for  life  insurance  before  an 
observant  doctor  who  recognizes  the  pal- 
pable artery,  makes  out  the  beginning  heart 
hypertrophy  and  the  slightly  accentuated 
second  aortic  sound.  The  patient  will  tell 
you  that  he  never  felt  better  in  his  life.  He 
gets  up  at  seven,  works  all  day,  plays  golf, 
drinks  his  three  to  six  whiskies,  and  is  proud 
of  his  physical  development.  But  the  great 
mass  of  people  are  not  fortunate  from  this 
standpoint.  They  do  not  seek  the  advice  of 
the  physician  until  they  are  stretched  out  in 
bed.  They  boast  of  the  fact  that  for  twenty 
years  they  have  never  had  a  doctor.  One  may 
well  say  that  it  is  a  problem  how  to  reach  such 
persons.  It  seems  to  me  that  there  can  be 
but  one  way  to  do  this.  The  people  must  be 
taught  that  the  duty  of  a  physician  is  just  as 
much  to  keep  them  in  health  as  it  is  to  bring 


104  Arteriosclerosis 

them  back  to  health  when  they  are  ill.  To  that 
end  people  should  be  taught  that  at  least 
twice  a  year  they  should  be  carefully  ex- 
amined. I  do  not  mean  that  the  patient 
should  present  himself  to  the  doctor  and,  af- 
ter a  few  questions  the  doctor  say  cheerfully 
"You  are  all  right".  The  patient  should  be 
systematically  examined.  That  means  a  re- 
moval of  the  clothing  and  examination  on  the 
bare  skin.  Such  co-operation  on  the  part  of 
patient  and  doctor  would  save  the  patient 
years  of  active  life  and  make  of  the  doctor, 
what  his  position  entitles  him  to,  the  bene- 
factor to  the  community.  Too  often  careless 
work  on  the  physician's  part  lulls  the  patient 
into  a  false  sense  of  security  and  he  wakes  up 
too  late  to  find  that  he  has  wasted  months  or 
years  of  life.  Early  diagnosis  of  arterio- 
sclerosis is  only  possible  in  exceptional  cases 
unless  people  present  themselves  to  the  phy- 
sician with  the  thought  in  mind  that  he  is  the 
guardian  of  health  as  well  as  the  healer. 

There  are  patients  who  go  to  the  ophthal- 
mologist for  failing  vision.  Physically  they 
feel  quite  well.  They  have  been  heavy 
eaters,  hard  workers,  men  and  women  who 


Diagnosis  and  Differential  Diagnosis  105 

have  been  under  great  mental  strain.  On 
examination  of  the  fundus  of  the  eye  there  is 
found  sHght  tortuosity  of  the  vessels  with 
possibly  areas  of  degeneration  in  the  retina. 
A  careful  physical  examination  will  usually 
reveal  the  signs  of  arteriocslerosis  else- 
where. We  have  mentioned  frequently 
high  tension  as  an  early  sign.  This  must 
be  taken  with  somewhat  of  a  reservation, 
for  this  reason:  not  infrequently  a 
persistent  high  tension  is  the  earliest 
sign  of  chronic  nephritis.  The  arteries 
may  be  pipe-stem  in  character  and  the 
heart  small  and  flabby.  However,  if  one 
watches  for  the  palpably  thickened  super- 
ficial arteries  (always  bearing  in  mind  the 
normal  palpability  as  age  advances)  and  the 
high  tension,  he  cannot  go  far  wrong  in  his 
treatment  whether  the  case  is  one  of  chronic 
nephritis  or  of  arteriosclerosis. 

There  is  also  this  to  bear  in  mind.  Arterio- 
sclerosis may  be  marked  in  some  vessels  and 
so  slight  in  the  peripheral  vessels  that  it  can- 
not with  certainty  be  made  out.  But  when 
the  radials  are  sclerosed  it  is  usually  the  case 
that  similar  changes  exist  in  other  parts.  Then 


106  Arteriosclerosis 

too,  there  may  be  marked  changes  at  the  root 
of  the  aorta  leading  to  sclerosis  of  the  coronary- 
vessels  alone,  and  the  first  intimation  that 
the  patient  or  anyone  else  has  that  there  is 
disease,  may  be  an  attack  of  angina  pectoris. 
Except  for  symptoms  on  the  part  of  the  heart 
there  is  no  way  to  make  the  diagnosis  of 
sclerosis  of  the  coronary  arteries. 

Differential  diagnosis — In  arriving  at  a 
diagnosis  when  the  question  is  whether  or  not 
arteriosclerosis  is  the  main  etiological  factor, 
the  most  important  fact  to  know  is  the  age  of 
the  patient.  Other  points  that  have  been 
dwelt  on  fully  must  of  necessity  also  be  borne 
in  mind. 

Possibly  the  chief  conditions  that  may  be 
confused  with  some  of  the  results  of  arterio- 
sclerosis are  pseudo  agina  pectoris  which  may 
be  mistaken  for  true  angina  pectoris,  and 
ulcer  of  the  stomach,  appendicitis  (?)  or 
other  inflammatory  abdominal  condition 
which  may  mistaken  for  angina  abdominalis. 

Differential  tables  are  sometimes  of  value 
in  fixing  the  chief  points  of  difference  gra- 
phically. 


Diagnosis  and  Differential  Diagnosis  107 


Pseudo  angina  pectoris 

Etiology  rather  certain; 
hysteria,  neurasthenia, 
toxic  agents,  and  reflex 
irritations. 


No  age  is  exempt.  Usu- 
ally in  young  people,  chiefly 
females. 

Paroxysms  of  pain  occur 
spontaneously,  are  periodic 
and  often  nocturnal. 

Pain,  while  severe,  is  dif- 
fuse and  sensation  is  of  dis- 
tension of  heart.  No  sense 
of  real  anguish. 

Duration  may  be  an  hour 
or  more. 

Restlessness  and  emo- 
tional symptoms  of  causa- 
tive conditions  are  promi- 
nent. 

Usually  no  increase  in  ar- 
terial tension. 

Prognosis  favorable. 


True  angina  pectoris 

Etiology  not  certain  but 
almost  always  associated 
with  arteriosclerosis  of 
the  coronary  arteries  and 
also   aortic   regurgitation. 

Age  is  important  fac- 
tor. Rare  before  forty, 
and  males  usually  affected. 

Paroxysms  brought  on 
by  overexertions  or  ex- 
cessive mental  emotion. 
Rarely  periodic. 

Intense  pain,  radiating 
down  arm;  heart  felt  as 
in  a  vise.  Sense  of  an- 
guish and  impending  dis- 
solution. 

Duration  from  few  sec- 
onds to  several   minutes. 

Silent  and  fixed  atti- 
tude, rigidity  rather  than 
restlessness. 

Arterial  tension  is  as  a 
rule  increased. 

Prognosis   most   vmfavor- 
able. 


In  differentiating  between  ulcer  of  the 
stomach  and  angina  abdominaUs  the  follow- 
ing points  may  be  of  service : 


108 


Arteriosclerosis 


Ulcer. 

Occurs  as  a  rule  in  young 
persons,  more  often  females. 


Pain  of  boring  character 
increased  by  food  and  by 
certain  positions  with  food 
in  stomach.  Felt  through 
to  left  of  spine. 

Occult  blood  found  in 
stools. 

Considerable  anemia  apt 
to  be  present. 

Arterial  tension  usually 
low. 


Angina  abdomlnalis. 

Only  occurs  in  adults 
over  forty  who  have  been 
heavy  eaters  and  drinkers, 
mostly  males. 

Pain  cramplike,  diffuse, 
although  more  localized 
in  epigastrium.  Not  nec- 
essarily any  connection 
with  food. 

No  occult  blood  in  stools 


Anemia  more  often  ab- 
sent. 

Arterial     tension    high. 
(Splanchnic  sclerosis) 


Diseases  in  which  arteriosclerosis  is 
COMMONLY  FOUND — There  are  certain  more 
or  less  chronic  diseases  in  which  arterio- 
sclerosis is  found  either  as  a  separate  disease 
or  as  a  result  of  the  chronic  disease  itself,  or 
the  sclerosis  may  be  the  cause  of  the  disease. 
As  examples  of  the  first  class  are  diabetes 
mellitus,  and  cirrhosis  of  the  liver.  As  ex- 
amples of  the  second  class  are  chronic  ne- 
phritis, gout,  syphilis,  lead  poisoning.  Ex- 
amples of  the  third  class  have  already  been 
fully  described.     Then  certain  rare  diseases 


Diagnosis  and  Differential  Diagnosis  109 

that  have  been  briefly  described  in  this 
chapter,  viz:  Raynaud's  disease  and  erythro- 
melalgia,  are  frequently  associated  with 
demonstrable  arteriosclerosis. 


CHAPTER   VIII. 

PROGNOSIS. 

In  a  disease  that  presents  as  many  vagaries 
as  arteriosclerosis,  it  is  not  possible  to  give 
a  certain  prognosis.  Unfortunately  we  do  not 
as  a  rule  see  the  arteriosclerotic  until  the 
disease  is  well  advanced,  or  even  after  some 
of  the  more  serious  complications  have  taken 
place.  By  that  time  the  condition  is  pro- 
gressive, and  while  the  prognosis  is  grave  the 
individual  may  live  a  number  of  years. 

It  is  fortunate  for  the  arteriosclerotic  that 
mild  grades  of  the  disease  are  compatible 
with  a  fairly  active  life.  The  disease  in  this 
stage  may  become  arrested  and  the  patient 
may  live  many  years.  Not  only  in  the  mild 
grades  is  this  possible.  Even  patients  with 
advanced  sclerosis  may  enjoy  good  health 
provided  the  organs  have  not  been  so  damaged 
as  to  render  them  unfit  to  perform  their  func- 
tions. The  frequency  with  which  we  see 
advanced  arteriosclerosis  at  the  post  mortem 
table  as  an  accidental  discovery,  attests  the 
truth  of  the  foregoing  statement.  Yet  how  often 


Prognosis  1 1 1 

does  it  happen  that  individuals,  apparently 
in  the  best  of  health,  suddenly  succumb  to  an 
asthmatic  or  uremic  attack,  an  apoplexy, 
cessation  of  the  heart  beat  or  a  rupture  of  the 
heart  due  to  arteriosclerosis ! 

In  order  to  arrive  at  an  intelligent  opinion 
in  regard  to  prognosis  certain  factors  must 
be  taken  into  consideration,  chief  of  which 
are;  the  seat  of  the  sclerosis,  the  probable 
stage,  the  existing  complications,  and,  last 
and  most  important,  the  patient  himself. 
The  whole  man  must  be  studied  and  even 
then  our  prognosis  must  be  most  guarded. 

It  is  much  more  dangerous  for  the  patient 
when  the  process  is  in  the  ascending  portion 
of  the  arch  of  the  aorta  than  when  it  has 
attacked  the  peripheral  arteries.  Here,  at 
the  root  of  the  aorta,  are  the  openings  of  the 
coronary  arteries  and  the  arteries  supplying 
the  brain  are  close  by.  The  coronary  arteries 
here  control  the  situation.  When  loud  mur- 
murs are  heard  at  the  aortic  orifice  and  the 
heart  is  evidently  diseased,  it  is  useful  to 
divide  the  endocarditis  into  two  types,  the 
arteriosclerotic  and  the  endocarditic.  The 
etiology  of  the  former  is  sclerosis  and  the 


112  Arteriosclerosis 

prognosis  is  grave  because  of  the  liability, 
nay  the  probability,  that  the  orifices  of  the 
coronary  arteries  will  become  narrowed.  The 
etiology  of  the  second  type  is  in  most  cases 
rheumatic  fever  or  some  other  infectious 
disease,  and  the  prognosis  is  far  better  than 
in  the  first  type.  True,thetwomay  be  com- 
bined. In  such  a  case,  the  prognosis  is  en- 
tirely dependent  upon  the  course  of  the 
arteriosclerosis. 

The  involvement  of  the  arteries  in  the 
kidneys  is  of  considerable  importance  for  it  is 
usually  bilateral  and  widespread.  As  a  rule 
the  disease  makes  but  slow  progress  provided 
that  the  general  condition  of  the  patient  is 
good,  but  at  any  time  from  a  slight  indis- 
cretion or  for  no  assignable  cause,  symptoms 
of  renal  insufficiency  may  appear  and  may 
rapidly  prove  fatal. 

It  must  not  be  thought  that  because  the  local- 
isation of  the  arteriosclerosis  in  the  peripheral 
arteries  is  usually  the  most  favorable  condition 
that  it  is  therefore  devoid  of  ill  effects.  On 
the  contrary,  very  serious,  even  fatal,  results 
may  be  brought  about  by  interference  with  the 
circulation  with  resultant  extensive  gangrene 


Prognosis  113 

of  the  part  supplied  by  the  diseased  arteries. 
The  amputation  of  a  portion  of  a  leg,  for 
instance,  may  relieve,  to  some  extent,  an  over- 
burdened heart  and  prove  life-saving  to  the 
patient,  but  the  neuritic  pains  are  not  neces- 
sarily relieved.  The  torture  from  these  pains 
may  be  excruciating. 

No  stage  of  the  disease  is  exempt  from 
its  particular  danger.  In  the  early  stages 
of  the  disease  before  the  artery  or  arteries 
have  had  time  to  become  strengthened  by 
proliferation  of  the  connective  tissue,  there 
is  the  danger  of  aneurysm.  Later,  the  very 
same  protective  mechanism  leads  to  stiffen- 
ing and  narrowing  of  the  arteries  and  hence 
to  increased  work  on  the  part  of  the  heart 
with  all  of  its  consequences.  Thrombosis 
is  favored,  and  where  atheromatous  ulcers 
are  formed,  embolism  is  to  be  feared. 

As  the  complications  and  results  of  arte- 
riosclerosis come  to  the  front  every  one  must 
be  considered  by  itself  and  as  if  it  were  the 
true  disease.  There  may  be  a  slight  apoplec- 
tic attack  from  which  the  patient  fully  re- 
covers, but  the  prognosis  is  now  of  a  grave 
character  as  the  chances  are  that  another 


1 14  Arteriosclerosis 

attack  may  supervene  and  carry  off  the 
subject.  Yet  after  an  apoplectic  attack 
patients  have  lived  for  many  years.  Prob- 
ably the  most  noted  illustration  of  this  is 
the  life  of  Pasteur.  He  had  at  forty-six 
hemiplegia  with  gradual  onset.  He  recovered 
with  a  resulting  slight  limp,  did  some  of  his 
best  work  after  the  stroke,  and  lived  to  be 
seventy- three  years  old.  Yet  the  exception 
but  proves  the  rule  and  the  prognosis  after 
one  apoplectic  stroke  should  always  be 
guarded. 

The  first  attack  of  cardiac  asthma  is  to  be 
looked  upon  as  the  beginning  of  the  end.  The 
end  may  be  postponed  for  some  time  but  it 
comes  nearer  with  every  subsequent  attack. 
One  may  recover  from  what  appears  to  be 
a  fatal  attack  of  cardiac  asthma  accompa- 
nied by  oedema  of  the  lungs  and  irregular, 
intermittent,  laboring  heart,  but  the  recov- 
ery is  slow  and  the  chances  that  the  next  at- 
tack will  be  the  fatal  one  are  increased. 

The  significance  of  albuminuria  is  difficult 
to  determine.  The  kidneys  secrete  albumen 
under  so  many  conditions  that  the  mere  pres- 
ence of  albumen  in  the  urine  may  have  but  lit- 


Prognosis  115 

tie  prognostic  value.  Many  cases  are  seen 
where  there  is  no  demonstrable  albumen, 
and  yet  the  patient  may  suddenly  have  a 
cerebral  hemorrhage.  As  a  general  rule  the 
urine  should  be  carefully  examined  but  not 
too  much  stress  should  be  laid  on  the  disco- 
very of  albumen  and  casts.  It  is  not  always 
possible  to  determine  the  extent  of  the  kidney 
lesion  by  the  urinary  examination,  yet  at  any 
time  a  uremic  attack  may  appear  and  prove 
fatal.  One  might  say  that  the  appearance  of 
albumen  in  the  urine  of  an  arteriosclerotic 
where  it  had  not  been  before,  is  a  bad  sign, 
and  in  making  a  prognosis  this  must  be  taken 
into  consideration. 

Bleeding  from  the  nose  is  not  infrequently 
seen  in  those  who  have  arteriosclerosis.  It 
can  hardly  be  called  a  dangerous  symptom 
as  it  can  always  be  controlled  by  tampons. 
There  are  times  when  epistaxis  is  decidedly 
beneficial  as  it  relieves  headache,  dizziness, 
and  may  avert  the  danger  of  a  hemorrhage 
into  the  brain  substance.  It  is  rare  to  have 
nose  bleed  except  in  cases  of  bigh  tension  in 
plethoric  individuals.  My  experience  has 
been  that  it  has  saved  me  the  trouble  of 


116  Arteriosclerosis 

bleeding  the  patient.  It  is  always  of  serious 
import  in  that  it  indicates  a  high  degree  of 
tension,  but  there  is  scarcely  ever  any  imme- 
diate danger  from  the  nose  bleed  itself. 

Intestinal  hemorrhage  is  always  a  grave 
sign.  As  has  been  shown,  arteriosclerosis 
of  the  splanchnic  vessels  not  infrequently  oc- 
curs, and  an  embolus  or  thrombus  may  com- 
pletely occlude  the  superior  mesenteric  ar- 
tery. The  chances  of  the  establishment  of 
a  collateral  circulation  are  small,  as  the  ar- 
teries of  the  intestines  are  end  arteries.  Ne- 
crosis of  the  part  follows,  blood  is  found  in 
the  stools,  and  perforation  or  gangrene,  or 
both,  are  apt  to  follow.  There  may  be  block- 
ing of  small  branches  only  leading  to  ulce- 
ration of  the  intestine.  Under  all  conditions 
the  prognosis  is  serious. 

The  general  condition  of  the  patient,  his 
build,  physical  strength,  powers  of  recupera- 
tion, etc.,  must  be  taken  into  account  in  giv- 
ing a  prognosis.  The  more  powerful  the  in- 
dividual the  more  favorable  as  a  rule  is  the 
prognosis  with  this  reservation  always  in 
mind,  that  the  greater  the  body  development 
the  greater  is  the  heart  hypertrophy  and  the 


Prognosis  117 

accidents  from  high  tension  must  not  be  over- 
looked. Many  puny  individuals  with  stiff, 
calcified  arteries  go  about  with  more  ease 
than  a  robust  man  with  thickened  arteries 
only.  The  differentiation  as  pointed  out  by 
Allbutt,  is  well  to  keep  in  mind  in  giving  a 
prognosis.  It  cannot  be  too  strongly  em- 
phasized that  it  is  the  whole  patient  that  we 
must  consider  and  not  any  one  system,  that  at 
the  time  happens  to  be  the  seat  of  greatest 
trouble,  and  by  its  group  of  symptoms  dom- 
inates the  picture. 

It  is  evident  from  what  has  been  said  that 
an  accurate  prognosis  in  arteriosclerosis  is 
no  easy  matter.  Were  arteriosclerosis  a 
simple  disease  of  an  acute  character  there 
might  be  grounds  for  giving  a  more  or  less 
definite  prognosis.  The  most  that  can  be 
said  is  that  arteriosclerosis  is  always  a  serious 
disease  from  the  time  that  symptoms  begin 
to  make  themselves  known.  The  gravity 
depends  altogether  on  the  seat  of  the  greatest 
arterial  changes,  and  is  necessarily  greater 
when  the  seat  is  in  the  brain  than  when  it  is 
in  the  legs  or  arms. 


118  Arteriosclerosis 

The  attitude  of  the  patient  himself  also 
determines  to  a  great  extent  the  prognosis. 
Some  men,  especially  those  who  have  always 
enjoyed  good  health,  turn  a  deaf  ear  to  warn- 
ings and  instead  of  ordering  their  lives  ac- 
cording to  the  advice  of  the  physician,  per- 
sist in  going  their  own  way  in  the  hope  that 
the  luck  that  has  always  been  with  them  will 
continue  to  stand  at  their  elbows.  Neither 
firmness  nor  pleadings  avail  with  some  men. 
The  only  salve  for  the  conscience  of  the  phy- 
sician is  that  he  has  done  his  best  to  steer 
the  patient  away  from  the  shoals  and  breakers. 
In  others  who  realize  their  condition  and  take 
advantage  of  the  advice  given  as  to  the  reg- 
ulation of  their  lives,  the  prognosis  is  gener- 
ally favorable. 

To  sum  up  the  chapter  in  a  few  words,  we 
should  say:  Always  remember  that  the 
patient  is  a  human  being,  study  his  habits 
and  character  and  mode  of  life;  look  at 
him  as  a  whole ;  take  everything  into  consid- 
eration, and  give  always  a  guarded  prognosis. 


CHAPTER   IX. 

PROPHYLAXIS. 

Arteriosclerosis  comes  to  almost  everyone 
who  lives  out  his  allotted  time  of  life.  As 
has  been  noted  within,  many  diseases  and 
many  habits  of  life  are  conducive  to  the  early 
appearance  of  arterial  degeneration.  Decay 
and  degeneration  of  the  tissues  are  necessary 
concomitants  of  advancing  years  and  none 
of  us  can  escape  growing  old.  From  the 
period  of  adolescence  certain  of  the  tissues 
are  commencing  a  retrograde  metamorpho- 
sis, and  hand  in  hand  with  this  goes  the  de- 
posit of  fibrous  tissue  which  later  may 
become  calcified.  The  arterial  tissue  is  no 
exception  to  this  rule,  and  we  have  already 
shown  that  certain  changes  normally  take 
place  as  the  individual  grows  older,  changes 
which  are  arteriosclerotic  in  type  and  are  quite 
like  those  caused  in  younger  people  by  many 
of  the  etiological  factors  of  the  disease.' 

We  are  absolutely  dependent  upon  the 
integrity  of  our  hearts  and  blood  vessels. 
Respiration  may  cease  and  be  carried  on  ar- 


120  Arteriosclerosis 

tificially  for  many  hours  while  the  heart  con- 
tinues to  beat.  Even  the  heart  has  been 
massaged  and  the  individual  has  been  brought 
back  to  life  after  its  pulsations  have  ceased, 
but  such  cases  are  few  in  number.  We  can- 
not live  without  the  heartbeat  and  the  pro- 
phylaxis of  arteriosclerosis  consists  in  the 
adjustment  of  our  lives  to  our  environment, 
so  that  we  may  get  the  maximum  amount 
of  work  accomplished  with  the  minimum 
amount  of  wear  and  tear  on  the  blood  vessels. 

The  struggle  for  existence  is  keen.  Com- 
petition in  every  profession  or  trade  is  ex- 
ceedingly acute,  so  much  so  that  to  rise 
to  the  head  in  any  branch  of  human 
activity  requires  exceptional  powers  of 
mind.  Among  those  who  are  entered  in  this 
keen  competition,  the  fittest  only  can  sur- 
vive for  any  period  of  time.  The  weaklings 
are  bound  to  succumb.  A  scion  of  halthye 
stock  will  stand  the  wear  and  tear  far  better 
than  will  the  progeny  of  diseased  parentage. 

It  is  only  necessary  to  call  attention  to 
the  part  that  alcohol,  syphilis  and  insanity 
play  in  heredity.  These  have  been  discussed 
fully  in  the  earlier  part  of  this  book. 


Prophylaxis  121 

We  live  rapidly,  burning  the  candle  at 
both  ends.  It  is  not  strange  that  so  many 
comparatively  young  m.en  and  women  grow 
old  prematurely.  While  heredity  is  a  factor 
as  far  as  the  prophylaxis  of  arteriosclerosis 
is  concerned,  of  far  more  importance  is  the 
mode  of  life  of  the  individual.  Scarcely  any 
of  us  lead  strictly  temperate  lives.  If  we 
do  not  abuse  our  bodies  by  excessive  eating 
and  drinking  and  so  wear  out  our  splanchnic 
vessels  and  cause  general  sclerosis  by  the 
high  tension  thereby  induced,  we  abuse  our 
bodies  by  excessive  brain  work  and  worry 
with  all  their  multitudinous  evils.  The  pro- 
phylaxis of  arteriosclerosis  might  well  be 
labeled  "The  Plea  for  A  More  Rational  Mode 
of  lyife".  Moderation  in  all  things  is  the  key- 
note to  health,  and  to  grow  old  gracefully 
is  an  art  that  admits  of  cultivation.  Ex- 
cesses of  any  kind  be  they  m.ental,  moral,  or 
physical,  tend  to  wear    out    the   organism. 

People  habitually  eat  too  much;  many 
drink  too  much.  They  throw  into  the  vas- 
cular system  excessive  fluid  combined  with 
toxic  products  that  cause  eventually  a  con- 
dition of  high  arterial  tension.     It  has  been 


122  Arteriosclerosis 

shown  how  poisonous  substances  absorbed 
from  the  intestines  have  some  influence  on 
the  blood  pressure.  Anything  that  causes 
constant  increase  of  pressure  should  be 
studiously  avoided. 

Mild  exercise  is  an  essential  feature  of  pro- 
phylaxis. One  may,  by  judicious  exercise  and 
diet,  make  of  himself  a  powerful  muscular  man 
without,  at  the  same  time,  raising  his  average 
blood  pressure.  The  man  who  goes  to  ex- 
cess and  continually  overburdens  his  heart,  will 
suffer  the  consequences,  for  the  bill  with 
compound  interest  will  be  charged  against 
him.  It  is  a  great  mistake  for  anyone  to 
work  incessantly  with  no  physical  relaxation 
of  any  kind,  and  yet,  after  all,  it  is  not  so  much 
physical  relaxation  that  is  necessary,  as  the 
pursuit  of  something  entirely  different,  so 
that  the  mind  may  be  carried  into  channels 
other  than  the  accustomed  routes.  Diver- 
sification of  interests  is  as  a  rule  restful.  That 
is  what  every  man  who  reaches  adult  life 
should  aim  at.  Hobbies  are  sometimes  the 
salvation  of  men.  They  may  be  ridden  hard, 
but  even  then  they  are  helpful  in  bearing  one 
completely  away  from  daily  cares  and  worries. 


Prophylaxis  123 

The  man  who  can  keep  the  balance  between 
his  mental  and  physical  work  is  the  man  who 
will,  other  things  being  equal,  live  the  longest 
and  enjoy  the  best  health. 

Nowadays  the  trend  of  medicine  is  towards 
prophylaxis.  We  give  the  State  authority 
to  control  epidemics  so  far  as  it  is  possible 
by  modern  measures  to  control  them. 

We  urge  over  and  over  again  the  value  of 
early  diagnosis  in  all  chronic  diseases,  for  we 
know  that  many  of  them,  and  this  applies 
particularly  to  arteriosclerosis,  could  be  pre- 
vented from  advancing  by  the  recognition 
of  the  condition  and  the  institution  of  proper 
hygienic  and  medicinal  treatment. 

It  is  the  patent  duty  of  every  physician  to 
instruct  the  members  of  his  clientele  in  the 
fundamental  rules  of  health.  Recently  the 
President  of  the  American  Medical  Associa- 
tion, in  his  address  before  the  1908  meeting, 
urged  the  dissemination  of  accurate  knowl- 
edge concerning  diseases  among  the  laity. 
While  this  may  be  done  by  City  and  State 
Boards  of  Health,  it  seems  far  better  for  the 
modern  trained  physician  to  work  among 
his  own  people.     With  concise  information 


124  Arteriosclerosis 

concerning  the  modes  of  infection  and  the 
dangers  of  waiting  until  a  disease  has  a  firm 
hold  before  consulting  the  health  mender, 
people  should  be  able  to  protect  themselves 
from  infections  and  be  able  to  nip  chronic 
processes  in  the  bud.  But  it  is  difficult  to 
turn  the  average  individual  away  from  the 
habit  of  having  a  drug-clerk  prescribe  a  dose 
of  medicine  for  the  ailment  that  troubles  him. 
It  is  really  unfortunate  that  most  of  the  pains 
and  aches  and  morbid  sensations  that  one  has 
speedily  pass  away  with  little  or  no  treatment. 
Herein  lies  the  strength  of  charlatanism  and 
quackery.  Unfortunate,  yes,  for  a  man  can 
not  tell  whether  the  trivial  complaint  from 
which  he  suffers  is  any  different  from  the  one 
that  was  so  easily  conquered  six  months 
ago.  But  instead  of  recovering,  he  grows 
worse.  Hope  that  springs  eternal  in  the  human 
breast,  leads  him  to  dilly-dally  until  he  at 
last  seeks  medical  advice,  only  to  find  that  the 
disease  has  made  such  progress  that  little 
can  be  done. 

Instruct  the  public  to  consult  the  doctors 
twice  a  year.  The  dentists  have  their 
patients   return  to   them  at  stated  intervals 


Prophylaxis  125 

only  to  see  if  all  is  well.  How  much  more 
rational  it  would  be  if  men  and  women  past 
the  age  of  forty  had  a  physical  examination 
made  twice  a  year  to  find  out  if  all  is  well. 

The  prophylaxis  of  arteriosclerosis  is 
moderation  in  all  the  duties  and  pleasures  of 
life.  This  in  no  sense  means  that  a  man  has 
to  nurse  himself  into  neurasthenia  for  fear 
that  something  will  happen  to  him.  As  one 
grows  in  years  exercise  should  not  be  as 
violent  as  it  was  when  younger,  and  food 
should  be  taken  in  smaller  quantities.  Many 
forms  of  exercise  suggest  themselves, 
particularly  walking  and  golf.  Walking  is  a 
much  neglected  form  of  exercise  which,  in 
these  modern  days  with  oiur  thousand  and 
one  means  of  locomotion,  is  becoming  almost 
extinct.  There  is  no  better  form  of  exercise 
than  graded  walking.  To  strengthen  the 
heart  selected  hill  climbing  is  one  of  the  best 
therapeutic  methods  that  we  have.  The 
patient  is  made  to  exercise  his  heart  just  as  he 
is  made  to  exercise  his  legs,  and  as  with 
exercise  of  voluntary  muscles  comes  increase 
in  strength,  so  by  fitting  exercise  may  the  heart 
muscle   be  increased  in  power.      A  warning 


126  Arteriosclerosis 

should  be  soiinded  however  against  over  ex- 
ercise. This  leads  naturally  to  hypertrophy 
with  all  its  disastrous  possibilities.  Men 
who  have  been  athletes  when  young  should 
guard  against  overeating  and  lack  of  ex- 
ercise as  they  grow  older.  Many  of  the  factors 
which  favor  the  developement  of  arteriosclero- 
sis are  already  there  and  a  sedentary,  ordinary 
life  such  as  office  all  day,  club  in  afternoon, 
a  few  drinks  and  much  rich  food,  will  inevit- 
ably lead  to  well  advanced  arterial  disease. 

Karl  Marx  in  his  famous  Socialistic  plat- 
form said  "No  rights  without  duties;  no 
duties  without  rights. "  So  we  may  para- 
phrase this  and  say  "No  brain  work  without 
moderate  physical  exercise  in  the  open  air; 
no  physical  exercise  without  moderate  brain 
work. ' ' 

There  is  yet  one  other  point  that  is  impor- 
tant, the  combination  of  concentrated 
brain  work  and  constant  whiskey  drinking. 
This  is  most  often  seen  in  men  of  forty-five  to 
fifty-five,  heads  of  large  business  concerns 
who  habitually  take  from  six  to  twelve  drinks  of 
whiskey  daily,  and  with  possibly  a  bottle  of 
wine  for  dinner.   Such  men  look  ruddy  and  in 


Prophylaxis  127 

prime  health  but  almost  invariably,  careful 
examination  will  reveal  unmistakable  signs  of 
arterial  disease.  There  is  usually  the  enlarged 
heart  and  pulse  of  high  tension  with  or  without 
the  trace  of  albumen  in  the  urine.  The  lurking 
danger  of  this  group  of  manifestations  has 
so  impressed  the  medical  directors  of  several 
of  the  large  insurance  companies  that  a  blood 
pressure  reading  must  be  made  on  all  appli- 
cants over  forty  years  of  age.  Should  high  blood 
pressure  be  found  the  premium  is  increased 
as  the  expectation  of  life  is  proportionately 
shorter  in  such  men  than  in  normal  persons. 
Therefore,  let  every  physician  act  his  part 
as  guardian  of  health.  Only  in  this  way  is 
the  prophylaxis  of  arteriosclerosis  possible. 


CHAPTER    X. 

TREATMENT. 

Although  it  has  been  rather  dogmatically 
stated  (vide  supra)  that  everyone  who  reaches 
old  age  has  arteriosclerosis,  it  must  not  be 
inferred  that  absolutely  no  exceptions  to 
this  rule  are  found.  Cases  are  known  where 
persons  of  ninety  years  even  had  soft  arte- 
ries, and  we  have  seen  persons  of  sixty  whose 
arteries  could  not  be  palpated.  When  in- 
fants and  children  are  seen  with  considerable 
sclerosis,  it  proves  that,  after  all,  it  is  the 
quality  of  the  tissue  even  more  than  the  wear 
and  tear,  that  is  the  determining  factor  in 
the  production  of  arteriosclerosis.  It  would 
be  well  if  those  who  cannot  bring  healthy 
progeny  into  the  world  were  to  leave  this 
duty  to  those  who  can. 

In  general  the  treatment  of  arteriosclerosis 
is  prophylactic  and  symptomatic.  In  the 
preceding  chapter  we  had  something  to  say 
about  prophylaxis  in  general;  we  must  again 
refer  to  it  in  detail. 


Treatment  129 

Arteriosclerosis  is  essentially  a  chronic 
progressive  disease,  and  the  secret  of  success 
in  the  management  of  it  is  not  to  treat  the 
disease  or  the  stage  of  the  disease,  but  to 
treat  the  patient  who  has  the  disease.  To 
infer  the  stage  of  the  disease  from  the  feeling 
of  the  sclerosed  artery,  may  lead  to  serious 
mistakes.  Persons  with  calcified  arteries 
may  be  perfectly  comfortable,  while 
those  with  only  moderate  thickening  may 
have  many  severe  symptoms.  The  key- 
note is  individualisation.  It  is  m-anifestly 
absurd  to  treat  the  laboring  man  with  his 
arteriosclerosis  as  one  would  treat  the  success- 
ful financier.  The  habits,  mode  of  life,  every 
detail,  should  be  studied  in  every  patient  if 
we  expect  to  gain  the  greatest  measure  of 
success  in  the  treatment.  One  may  treat 
fifty  patients  who  have  typhoid  fever  by  a 
routine  method  and  all  may  recover.  In- 
dividualising, while  of  great  value  in  the 
treatment  of  acute  diseases,  yet  is  not  abso- 
lutely essential  in  order  that  good  results 
may  be  obtained.  Far  different  is  it  when 
treating  a  disease  like  arteriosclerosis.  One 
who  relies  on  textbook  knowledge  will  find 


130  Arteriosclerosis 

himself  at  a  loss  to  know  what  to  do.  Text- 
books can  only  outline,  in  the  briefest  man- 
ner, the  average  case,  and  no  one  ever  sees 
the  average  book  case.  At  the  bedside  with 
the  patients  is  the  place  to  learn  therapeutics 
as  well  as  diagnosis.  All  that  can  be  hoped 
for  in  outlining  the  treatment  of  arterioscle- 
rosis is  to  lay  dov/n  a  few  principles.  The 
tact,  the  intuition,  the  subtle  something  that 
makes  the  successful  therapeutist,  can  not 
be  learned  from  books.  So  the  man  who 
treats  cases  by  rule  of  thumb  is  a  failure  from 
the  beginning.  There  are  certain  general 
principles  that  will  be  our  sheet  anchors  at 
all  times  and  for  all  cases.  The  art  of  vary- 
ing the  application  of  these  fundamentals  to 
suit  the  individual  case,  is  not  to  be  culled 
from  printed  words. 

Hygienic  treatment — Every  man  is  more 
or  less  the  arbiter  of  his  own  fate.  Granted 
that  he  has  good  tissue  to  begin  life,  his  own 
habits  and  actions  determine  his  span  of  com- 
fortable existence.  No  one  cares  to  live  after 
his  brain  begins  to  fail  and  the  failing  brain 
is  generally  due  to  disease  of  the  cranial  arte- 


Treatment  131 

ries.     The  hygienic  treatment  resolves  itself 
into  advice  in  regard  to  prophylaxis. 

First  and  foremost  is  exercise.  It  has 
seemed  to  us  that  the  revival  of  out-of-door 
sports  is  one  of  the  best  signs  of  promise  of 
the  preservation  of  a  virile,  hardy  race. 
That  women,  as  well  as  men,  indulge  in  the 
lighter  forms  of  out-of-door  exercise  should 
bring  it  about  that  the  coming  generation 
all  start  in  life  under  the  most  advantageous 
conditions  of  bodily  resistance. 

Among  all  the  forms  of  exercise,  golf  prob- 
ably is  the  best.  It  is  not  too  violent  for 
the  middle  aged  man,  yet  it  gives  the  young 
athlete  quite  enough  exercise  to  tire  him. 
It  is  played  in  the  open.  One  is  com- 
pelled to  walk  up  and  down  in  pleasant 
company,  for  golf  is  essentially  a  com- 
panionable game,  while  he  reaps  the  full 
benefit  of  the  invigorating  exercise.  The 
blood  courses  through  the  muscles  and  lungs 
more  rapidly :  the  contraction  of  the  skeletal 
muscles  serves  to  compress  the  veins  and  so 
to  aid  the  return  of  blood  to  the  heart:  the 
lungs  are  rendered  hyperemic,  deeper  and 
fuller  breaths   must  be  taken;  oxidation   is 


132  Arteriosclerosis 

necessarily  more  rapid,  and  effete  products, 
which  if  not  completely  oxidized  would  pos- 
sibly act  as  vasoconstrictors,  are  oxidized 
to  harmless  products  and  eliminated  with- 
out irritating  the  excretory  organs. 

Other  forms  of  out-of-door  exercise  that 
can  be  recommended  are  tennis,  canoeing, 
rowing,  fishing,  horseback  riding,  swimming, 
etc.  Tennis  is  the  most  violent  of  all  the 
sports  mxcntioned  and  might  readily  be  over- 
done. Rowing  as  practised  by  the  eights  at 
college  is  undoubtedly  too  violent  a  form  of 
exercise,  and  m.ay  be  productive  in  later  life 
of  very  grave  results.  Canoeing  is  a  delight- 
ful and  invigorating  exercise.  The  muscles 
of  the  arms,  shoulders,  and  trunk  are  espe- 
cially used,  the  leg  muscles  scarcely  at  all. 
Nevertheless  the  deep  breathing  that  neces- 
sarily comes  with  all  chest  exercises  aerates 
every  portion  of  the  lungs,  and  is  of  great 
benefit  to  the  whole  body. 

Swimming  as  an  exercise  has  much  to  rec- 
ommend it.  In  this  sport  all  the  muscles 
take  part  and  at  the  same  time  the  chest  is 
broadened  and  deepened.   • 


Treatment  133 

All  these  methods  of  using  the  muscles  to 
keep  ourself  in  trim,  so  to  speak,  are  part  and 
parcel  of  the  general  hygienic  mode  of  life 
that  is  conducive  to  a  healthy  old  age.  Exercise 
can  be  overdone,  as  eating  can  be  overdone. 
Both  are  essential  and  yet  both  can  be  the 
means  of  hastening  an  individual  to  a  pre- 
mature grave. 

When  the  arteriosclerosis  has  advanced 
so  far  that  it  is  easily  recognizable,  certain 
forms  of  exercise  should  be  absolutely  pro- 
hibited. Such  are  tennis,  rowing,  swimming.' 
Horseback  riding  to  be  allowed  must  be 
strictly  supervised.  At  times  this  may  be 
an  exceedingly  violent  exercise.  As  an  out- 
of-door  sport,  there  is  nothing  that  equals 
golf.  The  physician,  knowing  the  charac- 
ter of  the  course,  and  the  length  of  it,  can 
say  to  his  patient  that  he  may  play  six,  nine, 
twelve,  or  eighteen  holes,  depending  on  the 
patient's   condition. 

For  those  who  are  not  able  to  get  out,  ex- 
ercise in  the  room  with  the  windows  open 
must  take  the  place  of  out-of-door  sports. 
Here  the  use  of  chest  weights  is  a  most  excel- 
ent  means  of  keeping  up  to  the  tone  of  the 


134  Arteriosclerosis 

muscles.  By  adjusting  the  weights,  the  ex- 
ercise may  be  made  light,  medium,  or  heavy. 
Every  physician  should  be  familiar  with  the 
chestweight  exercises.  They  are  not  as  good 
as  open  air  exercise  but  they  undoubtedly 
have  been  the  means  of  saving  years  of  life  to 
many  patients  with  arterial  disease. 

There  comes  a  time  when  all  forms  of  ex- 
ercise must  be  prohibited  on  account  of  the 
dyspnoea,  oedema,  dizziness,  etc.  It  seems 
unwise  to  keep  such  a  patient  in  bed,  even 
though  the  oedema  be  considerable.  Once 
on  his  back  in  bed  he  becomes  weak,  and  the 
danger  of  oedema  of  the  lungs  or  hypostatic 
congestion  of  the  bases,  with  subsequent 
broncho-pneumonia,  is  very  great.  Although 
such  persons  can  not  exercise  actively,  they 
should  have  passive  exercise  in  the  form  of 
massage,  carefully  given,  so  that  no  injury 
is  done  to  the  rigid  vessels.  It  is  possible 
to  rupture  a  vessel,  the  walls  of  which  are 
encrusted  with  lime  salts,  and  full  of  small 
aneurysmal  dilatations.  Every  patient  must 
be  watched  carefully  and  measures  instituted 
for  the   individual. 


Treatment  135 

BaIvNEotheraphy — As  a  bracer  and  in- 
vigorator,  the  cold  or  cool  bath,  (shower  or 
tub)  in  the  morning  on  arising  can  be  highly 
recommended.  It  promotes  skin  activity, 
is  a  stimulant  to  the  bowels  and  kidneys  and 
to  the  general  circulation,  besides  being  cleans- 
ing. We  find  today  that  the  morning  bath 
has  become  such  a  necessity  to  the  average 
American  that  all  new  hotels  are  fitted 
with  private  baths,  and  old  hotels,  in  order 
to  get  patronage,  are  arranging  as  many  baths 
connected  with  sleeping  rooms  as  is  possi- 
ble.- Our  generation  assuredly  is  a  ruddy, 
clean-bodied  one.  What  the  actual  re- 
sults of  this  out-door  life  and  frequent 
bathing  will  be  for  the  race  remains  to  be 
seen,  but  one  cannot  but  feel  that  it  must 
build  up  a  stronger,  more  resistant  race  of 
people,  who  not  only  enjoy  better  health 
than  did  their  forefathers,  but  enjoy  it  longer. 

Not  every  one  can  stand  a  cold  bath.  It 
is  folly  to  urge  it  on  one  to  whom  it  is  dis- 
tasteful, or  on  one  who  does  not  feel  the  com- 
fortable glow  that  should  naturally  result. 
For  the  well,  or  those  with  a  tendency  to  ar- 
teriosclerosis, or  those  in  whose  families  there 


136  Arteriosclerosis 

have  been  several  members  who  had  early 
arteriosclerosis,  such  proceedings  as  recom- 
mended could  not  be  improved  upon.  How- 
ever, for  the  person  who  has  well  recognized 
sclerosis,  only  w^arm  baths  should  be  advised, 
and  these  not  daily.  The  water  should  be  at 
a  temperature  of  90-95  degrees  F.  Care 
should  be  taken  that  persons  sent  to  spas  be 
cautioned  against  hot  baths.  It  is  not  in- 
conceivable that  the  increased  force  of  the 
heart  beat  that  accompanies  a  hot  bath  might 
be  sufficient  to  rupture  a  sm.all  cranial  vessel. 
Hence,  Turkish  and  Russian  baths  should  be 
most  unqualifiedly  condem^ned.  As  a  mat- 
ter of  fact,  persons  vary  so  in  their  habits 
with  regard  to  bathing  that  what  might  suit 
one  person  would  do  another  m.uch  harm. 

Person Aiv  habits — The  personal  habits 
of  the  individual,  more  than  any  other  factor, 
determine  whether  or  not  arteriosclerosis 
sets  in  early  in  his  life.  The  m.an  or  woman 
who  is  moderate  in  eating  and  drinking,  sees 
that  the  kidneys  are  kept  in  good  condition, 
and  attends  strictly  to  regularity  of  the  bow- 
els, lays  a  good  basis  for  the  measure  of  health 
which  is  so  essential  for  happiness.    It  has  been 


Treatment  137 

shown  that  sclerosis  of  the  splanchnic  vessels 
may  be  due  to  constant  irritation  of  toxic 
products  elaborated  in  digesting  constantly 
enormous  meals.  In  obstinate  constipa- 
tion, many  poisons,  the  nature  of  which  we 
do  not  know,  are  absorbed  and  circulate  in 
the  blood.  We  have  not  sufficient  data  to 
prove  that  constipation  favors  the  produc- 
tion of  arteriosclerosis,  but  our  impression 
has  been  that  it  does  favor  it.  Constipation 
can  often  be  relieved  by  a  glass  of  water  be- 
fore breakfast,  a  regular  timxC  to  go  to  stool, 
and  abdominal  m.assage  or  exercises.  Some 
maintain  that  it  is  a  bad  habit  only,  and  can 
be  readily  overcome.  Whatever  is  done, 
avoid  leading  the  patient  into  the  drug  habit, 
for  the  last  state  of  the  patient  will  be  worse 
than  the  first.  Habits  of  sleep  are  not  of  such 
great  importance.  Most  persons  get  enough 
sleep  except  when  under  severe  m.ental  strain. 
Most  adults  need  from  seven  to  eight  hours 
sleep,  although  some  can  do  all  their  work 
and  keep  in  primiC  health  on  five  or  six  hours 
sleep. 

Tobacco  has  been  accused  of  causing  many 
ills  and  has  been  thereby  much  maligned. 


138  Arteriosclerosis 

We  can  not  see  that  the  use  of  tobacco  in 
any  form  in  moderation  is  harmful  to  most 
men.  Undoubtedly  the  blood  pressure  is  raised 
when  mild  tobacco  poisoning  occurs,  and  indi- 
vidual peculiarities  of  reaction  to  the  weed 
are  multitudinous.  But  to  condemn  off- 
hand the  use  of  plant  is  the  height  of  folly. 
There  is  no  reason  why  the  arteriosclerotic 
who  has  always  used  tobacco  in  moderation, 
should  not  continue  to  use  it,  whether  he 
smoke  cigarettes,  cigars,  or  pipe.  His  sup- 
ply should  be  decreased,  but  there  is  no  sense 
in  depriving  a  man  of  one  of  the  solaces  of  life, 
unless,  as  is  sometimes  the  case,  abstinence 
is  easier  to  the  patient  than  moderation. 

As  for  alcohol,  opinions  differ  widely. 
Some  see  in  alcohol  one  of  the  most  frequent 
causes  of  arteriosclerosis;  others  do  not  be- 
lieve that  the  part  played  by  alcohol  is  a  seri- 
ous one;  only  in  conjunction  with  other 
poisonous  substances  is  it  dangerous.  Probably 
unreasoning  fanaticism  has  had  much  to  do 
with  the  wholesale  condemnation  of  alcoholic 
beverages.  The  general  effect  of  alcohol  is 
to  lower  the  blood  pressure  by  causing  marked 
dilatation  of  all  the  vessels  of  the  skin.  True, 


Treatment  139 

the  alcohol  circulates  in  the  blood,  and  is  bro- 
ken up  in  the  liver,  and  this  organ  would  seem 
to  bear  the  brunt  of  the  harm  done.  Alco- 
holic drinks  in  moderation,  I  do  not  believe 
have  any  deleterious  effect  on  health.  On  the 
contrary,  I  believe  that  they  may  in  some  cases 
assist  digestion  and  assimilation.  Indiscrimin- 
ate indulgence  is  to  be  condemned,  as  is  over 
indulgence  in  exercise  or  eating.  What  may 
be  moderate  for  A,  might  be  excessive  for  B. 
Every  man  is  then  the  arbiter  of  his  own 
fortune  and  within  his  own  limits  can  indulge 
moderately  (a  relative  term  after  all)  with- 
out fear  of  doing  himself  harm.  In  advanced 
arteriosclerosis  it  is  necessary  to  decrease 
the  supply  of  alcohol  just  as  it  is  necessary  to 
cut  down  the  food  supply.  This  must  rest 
entirely  on  the  judgment  of  the  physician, 
who  must  not  act  arbitrarily,  but  must  have 
his  reasons  for  every  one  of  his  orders. 

Dietetic  treatment — Most  persons  eat  too 
much.  We  not  only  satisfy  our  hunger,  but 
we  satisfy  our  palates,  and,  instead  of  putting 
substantial  foodstuffs  into  our  stomachs,  we 
frequently  take  unto  ourselves  concoctions 
that  defy  description. 


140  Arteriosclerosis 

Food  stuffs  are  composed  of  one  or  all  of 
three  clases:  (i)  proteids,  (2)  fats,  (3)  car- 
bohydrates. As  examples  of  the  first  are  beef 
and  white  of  egg;  of  the  second,  the  oils, 
butter,  lard;  of  the  third,  sugar,  potato,  beet, 
corn,  etc. 

The  physiologists  and  chemists  have  shown 
us  that  both  endogenous  and  exogenous  uric 
acid  in  excess  will  cause  a  rise  of  blood  pres- 
sure, but  the  bodies  most  concerned  in  the 
production  of  elevated  blood  pressure  are  the 
purin  bodies,  those  organic  compounds  which 
are  formed  from  proteids,  and  represent 
chemically  a  step  in  the  oxidation  of  part  of  the 
proteid  molecule  to  uric  acid.  Red  meat 
contains  more  of  the  substances  producing 
purin  bodies  than  any  other  one  common 
food  stuff,  and  for  this  reason  the  excessive 
meat  eater  is,  ceteris  paribus,  more  apt  to 
develop  arteriosclerosis  comparatively  early 
in  life.  An  amusing  experience  of  Dr.  J. 
Mackenzie's  is  apropos.  He  writes,  "An 
elderly  man  came  to  see  me  complaining  of 
slight  attacks  of  angina  pectoris.  His 
arteries  were  thickened  and  his  pulse  very 
hard,  210  mm.  Hg.     He  is  a  brewer's  agent. 


Treatment  141 

I  said,  'You  must  give  up  beer  and  spirits. ' 
He  replied,  'I  am  a  teetotaler.'  'Well,  then, 
you  must  eat  less  butcher's  meat'.  'I'm  a 
vegetarian '  was  his  reply ! ' ' 

Nevertheless,  for  the  majority  of  persons 
too  much  meat  is  undoubtedly  harmful. 

The  fats  and  carbohydrates  contain  prac- 
tically no  substances  that  react  on  the  body 
of  the  ordinary  individual  in  a  deleterious 
manner  during  their  digestion.  The  extra 
work  that  is  put  on  the  heart  by  the  form- 
ation of  many  new  blood  vessels  in  adipose 
tissue  is  the  only  harmful  effect  of  over 
indulgence  in  these  food  stuffs. 

It  has  been  found  that  nitrogen  equilibrium 
can  be  maintained  at  a  wide  range  of  levels. 
Formerly  135-150  gms.  of  proteid  daily  were 
considered  necessary  for  a  man  doing  light 
work.  Now  it  is  known  that  half  that 
amount  is  sufficient  to  keep  one  in  nitro- 
genous equilibrium,  and  to  enable  one  to  keep 
his  weight.  A  person  at  rest  requires  even 
less  than  that.  One  who  is  engaged  in  hard 
physical  labor  burns  up  more  fuel  in  the 
muscles,  and  so  must  have  a  larger  fuel  supply. 


142  Arteriosclerosis 

Although  we  habitually  eat  too  much  we 
drink  too  little  water.  For  those  who  have 
any  form  of  arterial  disease  an  excess  of  fluid 
is  harmful,  as  the  vessels  become  filled  up  and 
a  condition  of  plethora  results,  which  neces- 
sarily reacts  injuriously  on  the  heart  and 
circulation.  The  drinking  of  a  glass  of 
water  during  meals  is,  I  believe,  good 
practice.  The  water  must  be  taken  mouthful 
at  a  time,  and  not  gulped  down.  If  this  is 
done,  there  results  sufficient  dilution  of  the 
solid  food  to  enable  the  gastric  juices  success- 
fully and  rapidly  to  reach  all  parts  of  the 
meal. 

Some  are  in  favor  of  a  rigid  milk  diet  for 
those  who  have  arteriosclerosis.  Some  men 
have  lived  on  nothing  but  milk  for  several 
years  and  have  not  only  kept  in  good  health, 
but  have  actually  gained  weight  and  led  at 
at  the  same  time  active  lives.  It  has  been 
held  by  others  that  rigid  milk  diet  is  positively 
harmful  on  account  of  the  relatively  large 
quantity  of  calcium  salts  that  are  ingested. 
This  was  thought  to  favor  the  deposition  of 
calcareous  material  in  the  walls  of  the  already 
diseased  arteries.     While  possibly  there  may 


Treatment  143 

be  some  danger  of  increased  calcification,  the 
majority  of  clinicians  are  in  favor  of  a  milk 
cure  given  at  intervals.  Thus  the  patient  is 
made  to  take  three  to  four  quarts  daily  for 
a  period  of  a  month.  There  is  then  a  gradual 
return  to  a  general  diet,  exclusive  of  meat,  for 
several  weeks,  then  another  rigid  milk  diet 
period. 

If  we  are  bold  enough  to  follow  Metchni- 
koff  in  his  theories  of  longevity,  we  might 
advise  resection  of  the  large  intestine,  on  the 
ground  that  it  is  an  enormous  culture  tube 
that  produces  prodigious  amounts  of 
poisonous  substances  which  are  thrown  into 
the  general  circulation.  To  combat  such  a 
grave  (?)  condition  as  the  carrying  of  several 
feet  of  large  intestine,  we  are  recommended 
to  take  buttermilk  or  milk  soured  by  means 
of  the  b.  acidus  lacticus.  Clinical  experience 
has  taught  that  in  arteriosclerosis  buttermilk 
is  of  great  value,  whether  it  be  the  natural 
product,  or  made  directly  from  sweet  milk  by 
the  addition  of  the  bacilli.  The  latter  is  a 
smoother  product  and  has,  to  my  mind,  a 
delightful  flavor.  Cases  that  cannot  take 
milk  or  any  other  food  will  often  take  butter- 


144  Atreriosclerosis 

milk,  and  do  well  on  this  restricted  diet. 
From  two  to  four  quarts  daily  should  be 
taken.  It  should  be  drunk  slowly  as  should 
milk. 

Medicinal — It  has  long  been  thought  that 
the  iodides  have  some  specific  effect  on  the  ad- 
vancing arteriosclerosis,  checking  its  spread, 
if  not  really  aiding  nature  to  a  limited  restora- 
tion of  the  diseased  arteries.  It  is  possible 
that  the  eulogies  upon  the  iodides  owe  their 
origin  to  the  successful  treatment  of  syphilitic 
arteriosclerosis,  in  which  condition  these 
drugs  have  a  specific  action.  However  that 
may  be,  there  is  no  doubt  that  the  adminis- 
tration of  sodium  or  potassium  iodide  is  good 
therapeutics  in  cases  of  arteriosclerosis. 

Unfortunately  many  persons  have  such 
irritable  stomachs  that  they  cannot  take  the 
iodides,  even  though  they  be  diluted  many 
times.  They  may  be  made  less  irritating  by 
giving  them  with  essence  of  pepsin.  Unless 
the  case  is  syphilitic,  it  is  doubtful  if  it  is  of 
value  to  increase  the  dose  gradually  until  a 
dram  or  even  more  is  taken  three  times  daily 
after  meals.  Usually  a  maximum  dose  of  ten 
grains   seems   to   be   quite   sufficient.     This 


Treatment  145 

maybe  taken  three  times  a  day,  well  diluted, 
for  three  months.  There  follows  a  month's 
rest,  then  the  treatment  is  resumed  for 
another  period  of  three  months,  and  so  on. 
Either  sodium  or  potassium  iodide  in  sat- 
urated solution  may  be  given.  The  sodium 
salt  is  possibly  less  irritating,  and  contains 
more  free  iodine  than  the  potassium  salt, 
although  the  latter  is  more  generally  used. 
The  strontium  iodide  may  also  be  used. 

One  sees  a  patient  now  and  then  who  cannot 
take  the  iodides,  however  they  may  be  com- 
bined. For  such  patients  one  may  obtain 
good  results  with  iodopin,  sajodin,  or  other 
of  the  preparations  put  up  by  reputable  firms. 
Personally,  I  have  never  yet  seen  a  patient 
who  could  not  take  the  ordinary  iodides  in 
some  form  or  other,  and  I  am  opposed  to 
ready  made  drugging. 

The  action  of  the  iodides  is  to  lower  the 
blood  pressure,  and  they  are  of  greatest  value 
when  the  blood  pressure  is  high,  and  when 
headache,  and  precordial  pain  are  present. 

When  the  case  is  moderately  advanced, 
very  mild  doses,  gr.  y^  morning  and  evening, 
of  the  thyroid  extract  may  be  given.     It  is 


146  Arteriosclerosis 

generally  believed  that  the  internal  secretion 
of  the  thyroid  and  the  adrenal  are  antagonistic. 
That  the  thyroid  secretion  lowers  blood 
pressure  is  certain,  possibly  on  account  of  its 
iodine  content.  Some  combinations  of  iodine- 
and  thyroid  such  as  the  iodothyroidin  have 
been  used  and  have  had  some  measure  of 
success  attributed  to  them. 

When  the  blood  pressure  is  high  and  there 
is  reason  to  believe  that  this  should  be  con- 
trolled, we  have  at  hand  a  group  of  drugs  which 
have  proved  of  inestimable  value .  The  nitrites 
have  the  power  of  markedly  reducing  the 
pressure,  and  of  equalizing  the  circulation. 
The  most  evanescent  of  these  drugs  is  amyl 
nitrite.  This  is  put  up  in  the  form  of  cap- 
sules, or  pearls,  containing  from  one  to  three 
minims,  which,  when  needed,  are  broken  in  a 
cloth  under  the  nostrils.  The  effect  is  almost 
instantaneous.  There  is  flushing  of  the  face 
and  other  peripheral  vessels  denoting  a 
relaxation  and  widening  of  the  bed  of  the 
blood  stream,  and  a  consequent  decrease  in 
the  pressure  in  the  arteries.  The  effects  of 
amyl  nitrite  however  are  soon  over.  It  is 
used  only  in  attacks  of  cardiac  spasm,  as  in 


Treatment  147 

angina  pectoris.  Nitroglycerin,  the  spiritus 
glonoinioftheU.S.  P.,  acts  in  about  the  same 
manner  as  amyl  nitrite  but  the  effects  last  lon- 
ger. One  drop  of  the  one  per  cent,  solution 
given  every  four  hours  and  increased  to  physio- 
logical effect,  then  reduced  just  below  the 
dosage  at  which  disagreeable  effects  follow, 
is  a  very  valuable  means  of  reducing  pro- 
nounced high  tension.  I  have  found  this 
drug  of  great  benefit  especially  in  cases 
where  arteriosclerosis  combined  with  chronic 
nephritis  causes  cardiac  asthma.  Still  an- 
other drug  which  I  have  found  of  service  in 
these  conditions,  one  whose  sphere  of  action 
is  somewhat  broader,  because  its  effects  are 
more  lasting,  is  sodium  nitrite.  This  is  given 
in  water  in  doses  of  one  to  three  grains  every 
four  hours.  Som.e  have  objected  to  the  use 
of  this  drug,  but  my  experience  has  made  me 
place  much  confidence  in  its  harmlessness, 
provided  that  the  patient  is  carefully  watched. 
This,  however,  applies  to  all  of  the  nitrite 
compounds.  For  a  mild  case,  one  often  finds 
that  sweet  spirits  of  nitre  is  sufficient  to  con- 
trol the  pressure  and  relieve  the  distressing 
symptoms,  and  it  is  undoubtedly  the  least 


148  Arteriosclerosis. 

harmful  of  all  the  nitrites.  Drugs  that  are 
of  great  value,  but  of  which  little  is  noted 
in  textbooks,  are  aconite  and  veratrum  viride. 
Both  of  these  drugs  are  well  known  to  be 
marked  circulatory  depressors.  Veratrum 
viride  in  my  experience  should  be  very 
cautiously  used,  and  never  used  unless  a 
trained  attendant  is  constantly  at  hand. 
With  regard  to  aconite  I  have  no  such 
feeling,  and  a  mixture  of  tincture  of  aconite 
and  spiritus  aetheris  nitrosi  may  be  given  for 
several  weeks  with  no  fear  of  doing  any  harm. 
Personally,  of  all  the  drugs  mentioned,  I 
prefer  the  nitrite  of  sodium  or  the  combination 
just  given.  They  may  be  advantageously 
alternated. 

After  all,  as  a  pressure  reducer,  no  drug  or 
group  of  drugs  can  take  the  place  of  absolute 
rest  in  bed  with  careful  regulation  of  the 
hygiene  and  diet  of  the  patient .  This  should  be 
borne  in  mind  and  a  course  of  this  treatment 
should  be  instituted  in  all  cases  of  persistent 
high  tension  in  which  symptoms  are  present. 

With  the  fibrolysin  of  Merck,  I  have  had 
no  experience.     Some  men  assert   that  they 


Treatment  149 

have  had  good  results  from  its  use,  but  on  the 
whole  the  evidence  is  not  highly  favorable. 

Morphine  is  invaluable.  No  drug  is  of 
such  value  in  the  nocturnal  dyspnoeic 
attacks  that  occur  in  the  late  stages  of 
arteriosclerosis  when  the  heart  or  the 
kidneys  are  failing.  Morphine  not  only  re- 
laxes spasm  and  quiets  the  cerebral  centres, 
but  is  an  actual  heart  stimulant  under  such 
conditions,  and  should  never  be  withheld,  as 
the  danger  of  the  patient's  becoming 
addicted  to  its  use  is  more  fanciful  than  real. 

As  heart  stimulants,  one  may  use  strych- 
nine, spartein,  caffein,  or  camphor.  In 
desperate  cases,  where  a  rapidly  diffusible 
stimulant  is  needed,  a  hypodermic  syringefull 
of  ether  may  be  given,  and  repeated  in  a 
short  while. 

Several  years  ago  a  so-called  serum  was 
brought  out  by  Trunecek  which  was  said  to 
have  a  favorable  effect  on  the  metabolism  of 
the  vessel  walls.  It  was  given  at  first  hypoder- 
matically  or  intravenously  but  the  former 
method  was  painful.  It  was  later  stated  that 
given  by  mouth  it  acted  just  as  well.  The  results 
with  the  Trunecek  serum  have  not  come  up 


150  Arteriosclerosis 

to  the  expectations  that  the  early  favorable 
reports  promised.  The  original  serum  was 
composed  as  follows:  NaCl,  4.92  gm.: 
Na2  SO4,  0.44  gm. ;  Na2  CO3,  0.21  gm. : 
K2  SO4,  0.40  gm.;  aqua  destil.  q.  s.  ad. 
Too.o  cc.  Later  this  was  modified  for  in- 
ternal use  to  the  following  prescription* 
R 

Natrii  chlor.  10.   gm. 

Natrii  sulphat.         i .   gm. 

Natrii  carbonat.       0.40  gm. 

Natrii  phosphat.      o .  30  gm. 

Calcii  phosphat. 

Magnesii  phosphat.  aa  0.75  gm. 
M.  Ft.  cachets  No.  XIII. 

The  contents  of  every  cachet  corresponds 
to  15  cc.  of  the  fluid  serum  or  to  150  cc.  of 
blood  serum.  The  preparation  called  anti- 
sclerosin  consists  of  the  salts  contained  in  the 
serum.  As  to  its  efficacy,  I  cannot  judge,  as 
I  have  never  felt  that  it  was  worth  while  to 
use  it.  Reports  Of  cases  in  which  it  has  been 
tried  do  not  speak  very  highly  of  it. 

In  the  general  treatment  of  arteriosclerosis, 
there  is  no  one  factor  of  more  importance 
than    the   regular    daily   bowel   movement. 


Treatment  151 

Attention  to  this  may  save  the  patient  much 
discomfort  and  even  acute  attacks  of  cardiac 
embarrassment.  The  choice  of  the  purgative 
is  immaterial,  with  this  reservation  only,  that 
the  mild  ones,  such  as  cascara,  rhubarb, 
licorice  powder  and"  the  mineral  waters, 
should  be  thoroughly  tried  before  we  resort  to 
the  more  drastic  purgatives.  The  old  Lady 
Webster  dinner  pill  is  an  excellent  tonic 
aperient.  When  the  heart  is  embarrassed  and 
oedema  of  the  legs  and  effusion  into  the  serous 
cavities  have  taken  place,  then  it  becomes 
necessary  to  use  the  drastic  purgatives 
that  cause  a  number  of  watery  movements. 
Bpsom  salts  given  in  concentrated  form, 
elaterin  gr.  1-12,  the  compound  cathartic 
pill,  blue  mass  and  scammony,  or  even  croton 
oil  may  be  used.  Since  the  observation  of  a 
greatly  congested '  intenstine  from  a  patient 
who  had  been  given  croton  oil,  I  have  ceased 
to  use  this  purgative,  and  I  doubt  much 
if  its  use  is  ever  justifiable  in  these  cases. 

The  management  of  the  ordinary  case  of 
arteriosclerosis  resolves  itself  into  a  careful 
hygienic  and  dietetic  regime  with  the  addi- 
tion of  the  iodides,  aconite,  or  the  nitrites. 


152  Arteriosclerosis 

A  diet  consisting  of  very  little  meat,  alcohol 
in  moderation  or  even  absolutely  prohibited, 
and  not  too  much  fluid  should  be  prescribed. 
Condiments  and  spices  should  also  be  used 
sparingly.  Cold  baths,  shower  baths,  cold 
and  hot  sheets  alternating,  are  of  great  bene- 
fit in  assisting  the  heart  to  do  its  best  work  by 
making  the  large  capillary  area  of  the  skin 
more  permeable.  It  is  not  true  that  such  baths 
raise  the  blood  pressure  so  markedly.  Certain 
acts,'  as  sneezing,  violent  coughing,  etc., 
increase  the  blood  pressure  much  more 
than  judicious  bathing. 

Symptomatic  treatment — The  fact  that 
arteriosclerosis  really  loses  much  of  its  own 
identity  and,  in  later  stages,  becomes  merged 
with  the  symptomatology  of  the  diseases  of 
various  organs,  as  the  kidney,  brain,  heart, 
compels  us  for  completeness'  sake  to  say  a 
few  words  about  the  treatment  of  these 
complications. 

One  of  the  results  of  arteriosclerosis  of  the 
coronary  arteries,  angina  pectoris,  demands 
prompt  treatment.  In  the  acute  attack, 
the  chief  object  is  to  relieve  the  spasm  and 
pain.  Pearls  of  amyl  nitrite  should  be  inhaled, 


Treatment  1 53 

and  morphine  sulphate  with  atropine  sulphate 
given  hypodermatically  at  the  very  earliest 
moment.  It  is  senseless  to  withhold  mor- 
phine. The  only  possible  reason  for  with- 
holding it  would  be  uncertainty  as  to  the 
diagnosis.  It  is  probably  better  to  err  on 
the  safe  side,  and  should  the  case  prove  to  be 
one  of  pseudo  angina,  in  the  next  attack 
sterile  water  can  be  given  instead  of  the  mor- 
phine and  atropine. 

When  a  patient  is  seen  in  the  condition  of 
broken  compensation  with  the  much  dilated 
heart,  anasarca,  dyspnoea  and  suppres- 
sion of  urine,  there  is  no  better  practice  than 
venesection.  Kspecially  is  this  valuable 
when  the  tension  is  still  fairly  high  and  the 
individual  is  robust.  Following  the  abstrac- 
tion of  six  to  eight  ounces  of  blood  the  whole 
picture  changes,  so  that  a  man  who  a  short 
while  before  was  apparently  at  death's  door, 
notices  his  surroundings  and  takes  an  in- 
terest again  in  life.  This  should  be  followed 
up  with  thorough  purgation,  and  cardiac 
stimulants  should  be  ordered.  In  such  cases 
digitalis  is  useful,  but  its  action  is  never  so 
striking  as  in  cases  of  this  general  character 


154  Arteriosclerosis 

due  to  uncompensated  valvular  disease.  It 
must  be  remembered  that  in  arteriosclerosis 
the  changes  in  the  myocardium  must  be  of 
a  considerable  grade  for  the  heart  to  give 
away.  Therefore,  digitalis  can  not  be  ex- 
pected to  act  on  a  diseased  muscle  as  it  acts 
on  a  comparatively  healthy  muscle.  It  is 
only  in  such  cases  of  broken  compensation 
that  digitalis  should  ever  be  used.  It  is  a 
vasoconstrictor  as  well  as  a  cardiac  stimu- 
lant, and  hence  in  choosing  a  drug  to  increase 
the  working  power  of  the  heart  when  there 
is  only  arteriosclerosis  and  a  weak  heart,  one 
should  put  digitalis  out  of  the  list.  It  is  ab- 
solutely contraindicated  in  Stokes-Adams 
syndrome. 

There  are  however  some  cases,  especially 
those  with  transudations,  when  digitalis  may 
be  carefully  tried  even  though  high  tension 
be  present.  It  is  sometimes  of  advantage  to 
combine  digitalis  with  the  nitrites  although 
they  are  said  to  be  physiologically  incom- 
patible. 

Still  another  drug  that  is  of  great  value 
in  conditions  such  as  have  been  described 
is  diuretin.   This  may  be  given  in  capsule  or 


Treatment  1 55 

tablets,  grs.  x.  three  times  daily.  There  is 
only  one  caution  to  express  in  the  use  of  this 
drug.  It  does  not  act  well  when  the  kidneys 
are  the  seat  of  chronic  inflammatory  changes ; 
in  fact,  actual  harm  may  be  done  by  admin- 
istering the  drug  under  such  conditions. 

For  the  pain  in  aneurysm  nothing  (except, 
of  course,  .morphine)  is  so  valuable  as  iodide 
of  potassium.  Patients  who  are  suffering 
agony,  when  put  to  bed  and  given  KI  grs.  x. 
three  times  a  day,  soon  lose  all  the  distress- 
ing symptoms.  This  applies  particularly 
to  aneurysms  of  the  arch  of  the  aorta. 

When  the  sclerosis  has  affected  the  cere- 
bral arteries  to  such  an  extent  that  symp- 
toms result,  the  case  is,  as  a  rule,  exceedingly 
grave.  Not  much  can  be  done  except  to  re- 
lieve the  headaches  and  keep  down  the  blood 
pressure,  if  this  is  high,  by  means  of  rest  in  bed, 
the  iodides,  aconite,  or  the  nitrites.  The 
cases  of  transient  monoplegias  or  hemiple- 
gias can  be  much  relieved  by  careful  hygienic 
measures  and  judicious  administration  of 
drugs.  Much  ingenuity  is  sometimes  re- 
quired  to    overcome   the   idiosyncracies    of 


1 56  Arteriosclerosis 

patients,  but  care  and  patience  will  succeed 
in  surmounting  all  such  difficulties. 

The  treatment  of  intermittent  claudica- 
tion is  the  treatment  of  arteriosclerosis  in 
general.  Sometimes  the  circulation  in  the 
affected  leg  or  legs  is  much  helped  by  daily 
warm  foot  baths.  Light  massage  might  be 
tried  and  the  galvanic  current  may  be  used 
once  or  twice  daily. 

There  are  a  few  distressing  symptoms  that 
occur  usually  late  in  the  disease,  when  com- 
plications have  already  occurred,  which  fre- 
quently baffle  the  therapeutic  skill  of  the 
physician.  The  chief  of  these,  insomnia, 
dyspnoea,  and  headache  may  not  be  late 
manifestations,  but  insomnia  and  headache 
are  frequently  associated  with  the  moder- 
ately advanced  stages  of  arteriosclerosis. 
At  times  all  the  symptoms  seem  to  be 
due  to  the  high  tension  the  relief  of  which 
causes  them  to  disappear.  There  are 
unfortunately  times  when  high  tension 
is  not  responsible  for  the  headache  and  in- 
somnia. Under  these  circumstances,  such 
drugs  as  trional,  veronal,  am^dene  hydrate, 
ammonol,   etc.,  may  be  tried  imtil  one  is 


Treatment  157 

found  to  give  sleep.  For  the  headaches  phe- 
nacetin  alone  or  in  combination  with  caffein 
and  bromide  of  sodium  may  be  tried.  Ace- 
tanilid,  cautiously  used,  is  at  times  of  value. 
There  have  been  cases  of  arteriosclerosis  with 
low  blood  pressure  accompanied  by  severe 
headaches  that  have  been  relieved  by  ergot. 
Codein  should  be  used  with  care  and  mor- 
phine only  as  a  very  last  resource. 

Great  care  must  always  be  exercised  in 
giving  drugs  that  depress  the  circulation  for 
it  is  easily  conceivable  that  more  harm  than 
good  can  come  from  injudicious  drugging.* 


*  Quite  recently  sodium  sulphocyanate  is  said  by  some 
to  give  excellent  results  in  the  treatment  of  arteriosclerosis. 
It  is  given  in  doses  of  a  fraction  of  a  grain  to  one  grain,  well 
diluted  with  water,  three  times  daily.  Those  who  recom- 
mend the  drug  emphasize  the  necessity  of  care  in  the 
administration.  It  should  not  be  given  for  any  length  of 
time  or  in  large  doses.  Frequent  blood  pressure  estima- 
tions should  also  be  made,  and  the  patient  should  be  care- 
fully watched.  The  drug  is  a  poison.  Experimentally 
in  vitro  it  has  the  power,  even  in  very  dilute  solution,  of 
dissolving  the  salts  of  calcium. 


CHAPTER    XI. 

PRACTICAL  SUGGESTIONS. 

The  time  spent  in  obtaining  a  careful  his- 
tory of  a  case  is  time  well  spent.  Often  the 
diagnosis  can  be  made  from  the  history  alone, 
the  physical  examination  merely  adding 
confirmation  to  the  data  already  obtained. 

The  younger  the  patient  who  has  arterio- 
sclerosis, the  more  probable  is  it  that  syphilis  is 
the  etiological  factor.  A  denial  of  infection 
should  have  little  weight  if  the  history  of 
possible  exposure  is  present.  Miscarriages 
in  a  woman  should  arouse  the  suspicion  of 
lues  in  her  husband. 

There  are  various  ways  of  examining  a 
patient  but  there  is  only  one  right  way;  the 
examination  should  be  made  on  the  bare 
skin.  However  skillful  one  may  be  in  the 
art  of  physical  diagnosis,  he  can  gather 
few  accurate  data  by  examining  over  the 
clothes  even  if  he  use  a  phonendoscope. 

The  immoderate  eater  is  laying  up  for  him- 
self a  wealth  of  trouble  at  the  time  when  he 


Practical  Suggestions  159 

can  least  afford  to  bear  it.  The  ounce  of 
advice  in  time  is  worth  more  to  him  than  the 
pounds  of  medicine  later. 

It  is  a  wise  maxim  never  to  drive  a  horse 
too  far.  Apply  that  to  the  human  being 
and  the  rule  holds  equally  well. 

There  may  be  no  symptoms  in  a  case  of 
advanced  arteriosclerosis.  Do  not  on  that 
account  neglect  to  advise  a  patient  in  whom 
the  disease  is  accidentally  discovered. 

Many  a  man  owes  a  debt  of  gratitude  to 
the  life  insurance  examiner.  He  rarely 
feels  grateful. 

When  a  competent  ophthalmologist  re- 
fers a  case  to  a  general  practitioner  with  the 
statement  that  he  believes  from  the  appear- 
ance of  the  fundus  of  the  eye  that  arterio- 
sclerotic changes  are  present  over  the  body, 
the  case  should  be  most  carefully  examined. 
The  earliest  diagnoses  are  not  infrequently 
made  by  the  ophthalmologist. 

It  is  the  part  of  wisdom  never  to  have  such 
a  firmly  preconceived  idea  of  the  diagnosis 
that  facts  observed  are  perverted  in  order  to 
fit  into  the  diagnosis.  Let  the  facts  speak 
for  themselves. 


1 60  Arteriosclerosis 

Beware  of  the  snap  diagnosis.  Even  in  a 
case  of  v>^ell  marked  arteriosclerosis  when 
the  diagnosis  seems  to  be  written  in  large 
letters  all  over  the  patient,  go  through' the 
routine.  Nine  times  out  of  ten  this  may 
seem  needless.  The  tenth  time  it  saves  your 
conscience  and  reputation.  Always  con- 
sider that  you  are  examining  a  tenth  case. 

Gradual  loss  of  weight  in  a  person  over 
fifty  years  old  should  arouse  the  suspicion 
of  arteriosclerosis. 

Do  not  call  the  nervous  symptoms  dis- 
played by  a  middle-aged  man  or  woman  neu- 
rasthenia until  you  have  ruled  out  all  or- 
ganic   causes,    particularly    arteriosclerosis. 

When  palpating  the  radial  artery,  always 
use  both  hands  according  to  the  method  al- 
ready described.  Pay  attention  to  the  super- 
ficial or  deep  situation  of  the  arter>^ 

The  examination  of  one  specimen  of  urine 
does  not  give  much  information  especially 
if  it  should  be  found  to  contain  no  abnormal 
elements.  Fairly  accurate  data  may  be 
gathered  from  the  mixed  night  and  morning 
urine;  most  accurate  data  from  the  twenty- 


Practical  Suggestions  161 

four  hour  specimen.  To  be  of  any  real  value 
there  should  be  frequent  examinations  of 
the  day's  excretion. 

In  measuring  the  day's  output  a  good  rule 
is  as  follows :  Begin  to  collect  urine  after  the 
first  morning's  micturition  and  collect  all 
including  the  first  quantity  passed  the  next 
morning.  It  is  best  to  examine  the  centri- 
fugated  urine  for  casts  even  though  no  albu- 
men be  present.  It  is  useless  to  look  for 
casts  in  an  alkaline  urine. 

Casts  are  not  infrequently  found  in  chem- 
ically normal  urine  from  a  middle-aged  patient . 

Blood  pressure  readings  should  always  be 
taken  with  the  patient  in  the  same  posture 
at  every  estimation.  At  the  first  examina- 
tion it  is  advisable  to  take  readings  from 
both  brachial  arteries.  Let  the  patient  sit 
comfortably  and  relax  all  muscles. 

As  a  rule  there  is  no  anomaly  of  the  urinary 
secretion,  yet  one  must  constantly  note  the 
amount  passed  in  twenty -four  hours  and  the 
frequency  of  micturition. 

Differentiate  as  soon  as  possible  between 
the  uncompensated  heart  caused  by  valvular 
disease  and  that  caused  by  arteriosclerosis. 


1 62  Arteriosclerosis 

There  is  a  difference  in  prognosis.  Both 
give  the  same  symptoms,  and  are  treated 
similarly  until  compensation  returns;  there- 
after the  management  of  the  two  forms  is 
different. 

Aortic  incompetence  that  comes  on  late  in  life 
is  generally  the  result  of  curling  of  the  free  mar- 
gins of  the  valves  caused  by  arteriosclerosis. 
Prognosis  is  grave  because  of  the  fact  that 
the  heart  muscle  also  is  the  seat  of  degenera- 
tive changes  and  compensatory  hypertrophy 
is  established  with  difficulty. 

When  laying  down  a  regime  for  a  patient, 
consider  his  disposition,  and  individualize 
the  treatment.  Remember  that  exercise 
is  an  essential  feature  of  the  hygiene  of  the 
patient's  life  but  do  not  forget  to  be  explicit 
about  the  amount  and  character  of  the  per- 
missible exercise. 

In  the  prophylaxis  of  arteriosclerosis,  a 
rational  mode  of  living  is  the  all-important 
factor.  As  a  rule,  the  less  meat  one  eats, 
the  less  is  the  liability  of  arterial  degenera- 
tion as  age  advances.  The  exceptions  to 
this  rule  are  many,   and  probably  depend 


Practical  Suggestions  163 

upon  the  character  of  the  "vital  rubber" 
with  which  the  individual  begins  life. 

The  diet  in  well  marked  cases  of  arterio- 
sclerosis should  be  carefully  selected  with 
regard  to  its  nutritive  and  non-irritating 
character.  Animal  proteids  should  be  spar- 
ingly used.  Milk  should  have  an  important 
place  in  the  dietary. 

No  drug  relieves  the  pain  of  uncomplicated 
aneurysm  as  surely  as  iodide  of    potassium. 

Iodides  frequently  upset  the  stomach.  Be 
cautious  in  the  use  of  them.  The  irritable 
stomach  may  turn  the  scales  against  your 
patient. 

Use  cardiac  stimulants  with  care  and  judg- 
ment. If  all  the  valuable  ammunition  is 
used  up  at  first,  the  fight  will  be  lost. 

When  you  want  to  use  digitalis,  remember 
two  important  points,  (i)  The  arterioscle- 
rotic heart  is  one  scarred  with  patches  of 
fibrous  myocarditis,  and  hence  is  no  longer 
a  heart  that  can  respond  with  every  fibre. 
(2)  Digitalis  contracts  the  arterioles  and 
thus   increases   the   peripheral   resistance. 

Remember  that  in  the  uncompensated 
heart  morphine  not  only  eases  the  oppressive 


1 64  Arteriosclerosis 

dyspnoea,  but  also  steadies  and  stimulates 
the  heart. 

See  to  it  that  the  patient  has  a  daily  move- 
mentof  the  bowels.  In  the  early  stage  try  the 
effect  of  the  mineral  waters  such  as  Pluto,  or 
Hunyadi  Janos,  or  artificial  Carlsbad  salts 
(Sprudel  salts) .  These  last  can  be  made  as  fol- 
lows: Sodium  chloride,  §i,  sodium  bicarbo- 
nate, §ii;  sodium  sulphate,  giv.  Take  two 
tablespoonsful  of  this  in  a  glass  of  hot  water 
before  breakfast.  Should  these  not  succeed, 
assist  the  action  of  the  drugs  by  the  use  of 
enemata.  The  pill  of  aloin,  strychnine  sul- 
phate, and  extract  of  cascara,with  the  addi- 
tion of  a  small  quantity  of  hyoscyamus,  is  a 
mild  tonic  purgative.  In  cases  of  constipation 
with  high  tension,  there  is  no  drug  as  valuable 
as  calomel  or  one  of  the  other  mercurials. 

Never  give  Epsom  salts  unless  copious 
watery  stools  are  desired  to  deplete  effusion 
into  the  serous  cavities  or  into  the  subcuta- 
neous tissue. 

Chronic  constipation  increases  the  gravity 
of  the  prognosis. 

In  case  of  suppression  of  urine  and  anas- 
arca, hot  air  packs  are  of  value.     The  patient 


Practical  Suggestions  165 

may  be  wrapped  in  a  hot  wet  sheet  and  cov- 
ered with  blankets.  I  do  not  beHeve  in  ad- 
ministering pilocarpine  to  assist  the  sweating. 
Remember  to  treat  the  patient  and  not 
the  disease.  The  careful  hygienic  and  die- 
tetic treatment,  combined  with  the  least 
amount  of  drugging,  is  the  best  and  most  ra- 
tional method  of  treatment. 


INDEX. 


PAGE. 

Adrenalin,  use  of, 17,  30 

Age, 45 

Alcohol, 138 

Allbutt,  Prof.  T.  C, 66,  85 

Amyl  nitrite, 147 

Aneurysm, 25 

Angina  Abdominalis, 108 

Angina  Pectoris, 107 

Angiosclerosis, 40 

Antisclerosin, 150 

Aorta,  thoracic, 11 

Arteries,  anatomy  of, 2 

brachial, 12 

innominate, 11 

in  infectious  diseases, 48 

in  Syphilis, 48 

left  carotid, 11 

left  subclavian, 11 

palpable, 30 

pulmonary, 38 

splanchnic, 14 

structure  of, 5,  20 

Arteriocapillary  fibrosis, i 


PAGE. 

Arteriosclerosis, i 

acquired, 42 

classes  of, 66 

congenital, 42 

diflfuse, 34 

nodular, 25 

senile, 35 

Asthma,  Cardiac, 114 

Atheromatous  abscess, 27 

Balneotherapy, 135 

Barium  chloride, 30 

Blood,  pressure  of, 9,  44 

diastolic, 12 

physiology  of, 9 

systolic, 12 

tension  of, 33 

velocity  of, 33 

Bright's  Disease, 14 

Brooks,  Harlow, 79 

Cabot, 51 

Caffein, 149 

Camphor, 149 

Capillaries,  structure  of, 7 

Cells,  chromaffin, 16 

Diabetes, 57 

Diagnosis, 97,   106 

Digitalin, 30 

Digitalis, 1 54 

Diuretin, 1 54 

Drug  intoxications, 50 


PAGE. 

Dyspnoea, 57 

Epistaxis, 115 

Erlanger, 75 

Brythromelalgia, 65,  94 

Etiology, 41 

Ewald  test  meal, 58 

Exercise, 122,  131 

Fabyan, 21 

Fibrolysin, 148 

Habits,  personal, 136 

Hemorrhage,  intestinal, 116 

Hemiplegia, 36 

Henle,  membrane  of, 4 

Heart, 59 

hypertrophy  of  the, 52 

His,  bundle  of, 75 

Holmes,  Dr.  O.  W., 42 

Hypertension, 43,  58 

Intestinal  Hemorrhage, 116 

Iodides, 145 

Janeway's  Instrument, 13 

Kidneys, 38 

Lead,  absorption  of, 48 

intoxication  of, 50 

Lymphatics, 4 

Mental  Strain, 52 

Mesaortitis 25 

Mitchell,  S.  Weir, 94 

Milk  diet, 142 

Morphine, .' 149 


PAGE. 

Muscular  overwork, 52 

Nephritis, 14 

Nervous  System, 16 

Nerves  vasomotor, 6 

Neuralgias, 56 

Neurasthenia, 57 

Nicotine, 30 

Nitre,  sweet  spirits  of, 147 

Nitrogen  equilibrium, 141 

Nitroglycerin, 147 

Occupation, 47 

Oedema, 57 

Osier, 45,  50,  75 

Overeating, 51 

Paralysis, 57 

Pasteur, 114 

Pathology, 18 

Pathognomonic  Signs, 66 

Phlebosclerosis, .  39 

Physical  Signs, 55 

Physostigmin, 30 

Prognosis, no 

Prophylaxis, 118 

Pulse  Pressure, 12 

Pyrosis, 57 

Race, 46 

Raynaud's  Disease, 93 

Renal  Disease, 53 

Rest,  treatment  by, 148 

Riva-Rocci  instrument, 12 


PAGE. 

Robinson.G.  C, 77 

Sex, 46 

Sodium  nitrite, 147 

Spartein, 149 

Spirochetae  pallidae, 25 

Splanchnic  area, 34 

Stanton  Instrument, 13 

Stokes- Adams  syndrome, 75,  87 

Strychnine, 149 

Symptoms, 55 

abdominal, 78 

cardiac, 72 

cerebral, 84 

nervous, 64 

ocular, 62 

renal, 77 

spinal, 88 

Syphihs, 25,  49 

Systole, II 

Thayer, 21,  22,  49 

Thebesius,  vessels  of, 74 

Thoma, 23 

Thyroid  extract, 145 

Tobacco, 137 

Treatment, 128 

dietetic, 139 

hygienic, 130 

medicinal, 144 

symptomatic, 152 

Trunecek  Serum, 145 


PAGE. 

Tuberculosis, 57 

Tunica  media, 3 

Ulcer  of  the  stomach, 108 

Vascular  System, 2 

Vaso  motor  effects, 93 

Vasa  Vasorum, 4 

Veins,  structure  of, , 7 

sclerosis  of,  39 

Venesection, 153 

Veratrum  Viride, 148 

Vertigo, 56 


DUE  DATE 

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Arteriosclerosis. 


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